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HomeMy WebLinkAbout1497A (8) ' WORKERS'COMPENSATION DECLARATION � � H APrPLICATION FOR PERMIT � �7 IrJ ' I hereby affirm that I have a certifimte of consen�to seff � . ��./ G''`i � . insure,o�o ceriifica�e of Workers'Compensation Insurance,-- --- . -_ ,�. - - I I cg(t�itedc����eof(Sec.38 ,Lab. ) �en3�c . .� TILATING - AIR CONDITIONING �� �/j�/� c . . . .. .�..CE-818�REV 10/81)-- �-. .. -�. - ---.. .:_ ._ . .❑o�i1 cyTl� Compan 't _. ._. .. . . . . ... ,,y����U : Certifed copy is hereby f�m�shed. ' COUNTY OF LOS ANGELES - BUILDING AND SAFETY -N' . �eniiied copy.is filed with the coont�6uilding inspeo♦, -� - � � FOR APPUCANT TO FILL IN ; - BUilpiwG qlSr/ �+ / _ tion depertment. ` �P� [PRINT OR 7YPE ONIY), � � AD�RESS p�v/7��^�,a;jd p( � - Dale �G' GJ Applitont NO. TYPE OF APPLIANCE OR EOUIPMEM � FEE ���ITv J "'� � S � ' � CERTIFICATE�OF EXEMPTION FROM WORKERS' - - NEAREST ' � � � COMPENSATION INSURANCE � . CROSS ST. � (This s�cfian nwd nat ba templel�d fF}ha work fnvolvad 6y-� ABSORMION UNIT,BTU DISLRiCT NO. GROCESSE�6Y ' � tha pormlt is for ona hundrad dollars(5100)or.le�s.) . � ' � � � � l certify thot in the�performance�of the�work for which ihis� .- A�R HnNDUNGUNrt,CFM� �� �. permit is issued,I shall not amploy any person in any monner gp��ER,BTU � ��' � • so os to become subjetl to the Workers'Compensation Laws. , araapvnis ,onrt INS�EC70R'S SIGNATVRE , , � Date � � ' �appticonf -� � COMPRESSOR,BTU � ROUGH � ,1Ssi.S� � �, , NOTICE TO APPLICANT: If,ofter making this Certificote Of VENTILATIONSYSTEM � FINAL ��g$� . Exemplion, you should become�xubjed to the�Workers' . � Compensorion provis�ons of�he labor Code,�you mus+for�h- ¢vnaoannve cootea � � ' � ' VALIDATION � , �� ' with comply with�wch provisions or Ihis permit shall be � i deemed revoked. � - � ` � � FURNACE: fAU - GR VITY �� '� � - � � �� . . . LICENSED CONTRACTORS DECLARATION . - I FIOOR 8TU �U � � I hereby affirm ihat I om licensed under provisions of Chopter 9 �� HEA�R; SUSPENDEo UNIT_ � " • ' � '(mmmencing with Setlion 7000)of Division 3 of ihe Business WA0. � � and Professions Co , �'ense Is in full force and effetl:� � � � �--��--- � � �����'-�� - � - . �' � I . S a : License Number � Lic.Class��2'U - . . . . . .. .. _ _. _ . -, � . � V �' �. Contratlo � G Date ��d!/(�S Z.. . _ . . . . .. �.. ... .. ... . � � . . � -�- ❑�� I am exempt under Sec. � . .. .._ .. ... ._ . . ��/j Q 7 A a � e.sv.c.for�h�z rea:oo � Plan check fee -- PERMIT ISSUING FEE S p,5- �• • • • •8 z Dote: Signature - 70TAL FEE ! �J .S . I • •7 Q,7$ . - � OWNER-BUILbER DECLARATION , Pv,N CNECK qvvuCANr . � � - � � � � � � � � � �7(�']5� �. I hereby affirm thot I om exempt irom the Canfmctor's License . ► . Law for Ihe following reason(Section 7031.5,.Business and NAME � - �Q'z�=$�J � �ProfessionsCode)i � � �� ,� � ��` . � � � � � ❑ I, as owner of fhe properfy, or my employees wilh ADDRE55 � ' � . - � - �� wages as Iheir sole compensalion,will do the work and� � , � . � the strunure Is nor in�ended or offered for sale(Section CITV , iEt.NO. . 7044,Business and Professions Code).� � �� / �. - - . . . . . . . OWNER 7� , . ❑ I,as owner o4 the property,am extlosively Contracting _ MAII� � 7J � - - with licensed tontracrors to construct the project(Sea � qoDRE55 ! G� � � - � tian 7044,Bvsiness and Professions Code). � . . ' CONSTRUCTION IENDING AGENCY '� - - CiTV � ����-'- -' �.'NO.�� � � �' I hereby affirm thai ihere is a cons�roction lending agency for ' �� � �. ' . �. Ihe performante of the work for which this permit is issued - COMaACi � - �� f�/Y��������--�" � � (Set.3097,Civ.C.). . � ' ... . .. . ►..._...... _ �__ ___ ... ._ . _._ _.._ _ ... .._.... :. . . . ._ - ADDRESS 3I G.I. .iL�.-/�"�—'. .. . .._. ,_. . :._ . •�. .... _. . . ._ _._. �. Lender's Nome , . � . . . tliV� �__ � . . . TEL NO. S'�G U-C� � ,. _ .. � _ . � Lender's Address � C�u �� � � �����- ���-� � ' I certify Ihat I hove reod this opplimlion and stote thal the -- �j�NSE NO. �/-/ CLA55� �—�L� .- �� - �� _.. .._ . ... .. ._. . .___._ " "obove inlormotion is correa.I ogree to comply wilh al�CouMy . . �. . � ordinances and State laws rela�ing to 6uilding conslrudion, �. . � �, � " ...... .. . .. _. .... ._.. ____..�._'_.—.. ' and hereby oothorixe represeMatives of this Coanry to enler �� . � �� � ' ����� � - ����-� '- ��- -�� - � pon the above-men�ioned propeny for inspection purposes. ___.�.SEE REVERSE FOREXPLANATORY LANGUAGE__ .. - -7 .__ . . . ____._..__. . .._.. . ,.. .... _. . __ ... , .. ����'�" / � . . �. . � . ..� Siqnoture of Applicom or Agen� Data� . . .-.. . ...:.. _..._ ..._ ._ .._. _J_ .. .. , �1 � � . . � . � .. � � : I �. . . � p � . '.J:� �. � . .� � � � �' ' ,� 7,f.,... . .. �,'. i . ., Y . . 1 �_ .i " ' . . i' . � .. ,. . i . . .. . . ° .:` ; '' �S '('- .�;, _ = . ��,..-. . . OWNER-6U�ILDER DECLARA710N ' 'INSPECTO�'S NOTES , 1 �z , J 1.;7<, �ta`:� y.�.,i..7�,...� c .�.. ',!_ . . . .� . � Y� ''1�1�ar 6y1 ffirm�ha�I am e empt from the CoMractor's � . .. � . ._ ,�.. �.�-,-_ .r..., .. '� � � 4icenso Law for�.1ha�follawin� reason.(Sectlon 7031.5, � � � .. .� . .� _. .__.. _ ' _ . . . .... _..� � _ (,.�\ � . � .1`.1`1 �. ._.. ...� -_ �._ i �. , ,. � .._ , 8uslness an Pro esslons Co e)Any Ntyo c unty htch � '�requirea a permii�to conslruc! aleer�1 pr� e,�dembfish. �,��, � � 'o�repoJr�anytst�uc}ure,p�l r?o.�ls fss once, 0750�e cl �V.�I � C f`_°- _ .. �t� .- _ , . . � . �ulresihbapplitanlforsuchpermRlofiloaslgnedstote- ��� � ��_ menf fhof he is llcensedpursuanf ro the provislons o/the � �. . '. _ I �Y_._�\����\ �t�t � � � � ;, ` � � , ; � �� � ; . Coniradoi�s,License Low(Chapter�9�(rommenNng wi�h I -��' , . �., � F�-.. ��. . --- - ._ ... .� �..' ��%r'fhe 7olle, d DlXi�slon 3 0l Ihe 6us ness ond Proles� � ' \ � � ^ \ i�� � ions Code or thal he fs�e empf tberel�om pnrl fho�bosls ' � .� � � � r � • g �mpNon A y�v)olof�on of�SecHon , .� � � . . �.r� c not � . � .-._— --_. - '..--_'_--. ._.. -_-_.__ � � � by`6ny appflcant for o permlt subjeds 1Fo�oppli• • _. ..�..• ,�- � � ' ' � --------. .- ...----- � '�' �- .I ! r. �.sonl�o,d clvll penally ol morc..ihan�Ovv hundred ]031 5 . .�:, _ .__. . I -..____. _..--. ---. .__.,--'._.__._..__ ._.. dollars(E500J.: � . � � � �� - -� ---- � �' " � ''% ❑I,as owner o1 Ihe ropert will do the work,ond I } __— _ � ' :__ _ � , y � i ^(Sec.'7044rBuslness and Proles offered fo sale_"., " i I . . . .' � i .- >r .. .:a,� . - -- --...- - -..'- ' ---- -�---- - --- ilonsCode:�-�iheConMoc E"�.�i/' :'�Y�,'�,' .'� ; �. . . ,�,. . , i � ...�����,�or's Ltcense Law does not opplylo an owncr of property ��� ___1, � f U.•-who�builds or improves�fhcreon,�',and who does.suth � � � \ j work hlmseH provlded Ifiai such improvemen}s ore nof i . ! } )!�_�, i . s S� - - - � inlended or o(lered(or�.iale.'I(,"howe6e�,fho bullding or i ' � ----. - ----.__..� � - , ,;:�Improvemenl Is s.ofd wlihln one year o1 compleflon;the I � .��� � ��' �� -��-�.�-'ownerbvildor.w(Ufiovefheburdenoiprovingfhathe�did i � � ' '--------- ' . . .-- . -_ . . . -- _ . --' � � ' • � : i :-� , � �-''���!nof bulfd or7mprove lor�l�ie pvrpose ol sale.J��' � ' > L � - - - i �-S. �,. i , r. �.•� "�� �� ..--... '��_ .`. ._.___�. .y_ __�. . ..__! ' '�tmclin❑g wi hslcensed contrac�o s�to�conseuct thceproject I' 1 . - t� - - (Sec.7044)8uslness ond Prolessla is Code:ihe ConHac- I �� � R � • � � -tor s llcenso Low doe!not apPly io a`owner of prqperty � '- A,`Q j� ��:. � '' s'-'-` '���--------�--- --- --� - �� �--�-� - �-- � who bui(ds ar lmproves fhereon,and who canlracls for I ,.. . _ � e __--_ ,..._.,_._._ . .._. ' '-'-' .. . '. . svch projec}s w fh a conl�od van�fo '"� ] or(s)licensed purs �� • • • •tk � . I . ...... . .. . ..._..�..- , ..� -� - -}Fe Canfrntlar's Lkrnsc LawJ:�� .. �% ° . �.- . _. . .._ .-:..., � � - --- - ----- - -�--'----�----......� '.:t'.1,^ � \,i.� . - �. .n ----'--... I �� i i - --- ----_.-_ .___ _...__ . .. • . ,., . , �„�;, . 1--. . _ . _ .. _._�: .---�-� - - . _-- �-_.- ..--�--.. . ._._._ ,� . ,. _._._________. ' ��1�"• • • � � . .. ,. .. I am exertipt u�der Sec � � -.�:P 1 � � _ : . i ', . t- B&P.C.for this reason ' � �: . ,_. . ' , .... 1 .. . '-��, � . � - --;� - ` ,;:\ Date � . . L � . . - "> � �, ` ,t �j : � � ��_ _ \---- ' 1,• '�� ., � .),�` __j �-Owner . : , J i >___.--- --- - �C1 '�:\_ ! . ,i. . � . . ,. -_. � ..,.. ., � _, � �. v-.� .,-�._,•,�_ ,._ . . . , �., - . .. , . , _ � --- --- - _ -- .,,._. - - - _ _. ' INSPECTOR'S NOTES i� _ . � � - - �. ..:-: � . _. .� ... __ ,.._.. '.-_. .� ..` ' 1 � - ._ . ,,. ,_ ,� ; , , , �-� .. .. , . . .. . _ ,_� . ., - � . . _ . ._ ----�--- - -'�-_- .,. . . . � � --1 `i, �- ---.- _ ._ _ _ __ i .�.�..._.___,____..._--_____.___. _.._... ___._ ._..-' , . . � , . ,...,,.. .� ...,.,,.,.., �.,� :,, - • .--� . �� � �_:� `��-- � � - -_. i ' . .. . � � �.5 , �� 5 ., ; \�. i