HomeMy WebLinkAbout1501A WORKERS'COMPENSATIONDECLARATION qpp��CATION FOR PERMIT y37/� . j�
I hereby affirm Ihaf I have a cerlificate of consent lo self
insure,or a certificare of Workers'Compensation Insurance, 76A36aC • HEATING - VENTILATING - AIR CONDITIONING L
a certifie�co.py��reoi(Sec.3800,Lab. ) '
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❑ y Compan
Ce tified topy is hereby(urnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ��Q��
Cerlified copy is filed with 1he county building i�spec- � FOR APPLICANT TO FILL IN BUiIDING ,/ �
lion deporimenf. (PRINT OR TYPE ONLYJ .4DDRE55 0 ys [..���j� �—D
Date /G—/G—�7 APPlitant •-�--� /g . ioo^uTv ,�c,_,,,�...�p � !3l„G /O
NO. TYVE OF AVPLIANGE OR EOUIPMENT fEE
CERTIFICATE OF EXEMPTION FROM WO CERS' NEAREST "
COMPENSATION INSURANCE CROSS S7. ..fLy .�ti.�a
(Thii s�ct�o�noed not ba eomplNod iF tha work i�volv�d by ABSORPTiON UNiT,BTU �IS�A�CT NO. VROCESSED BY
the p�rmft I�for one hundr�d dollars(5100)or I�cs.) qIR HANDIING UNIT,CFM "
I certify ihat in the performance of ihe work for which this � �Z��
permit is iss�ed,I shall not employ ony person in any monner BOIIER,BTU
so as to become wbject to the Workers'Compensation Laws. arvcovnis DAIE INSFfCTOR'S SIGNAIURE
Dote eppliconl COMPRESSOR,BTU ROUGH ��QEB
NOTICE TO AGPLICANT: If, oi�er making lhis Certificale of vEN7IlATION Sv57EM FINAL �l�t— '�
Exemp�ion, you shoold become subject to the Workers'
Compensalion provisions of fhe Lobor Code,you mos�forth- EVA70RATIVE COOLER VAIIDATION
with comply with s�th provisions or ihis permit sholl be
deemed revoked. FURNACE: FAU G AVITY
� LICENSED CONTRACTORS DECLARATION ROOR BTU s �� �
I here6y affirm that I am licensed under provisions af Chapter 9 HEATER: SUSPFNDED UNIT_ � �
'(commencing with Secfion 7000)of Division 3 of the Business WA«
and Professions Code,and my license is in full force and ef(ect. • � }
� �� a
Ucense Nomber�G9Y9G Lic.Class ��z V � , , V
�J � � � �U--��"�7 � K
Contrpctor-.�L_ Date ' � . 0
f-
❑ I om ezempl under Sec. a
Plan check fee 1 $Q 1 A
6.Bv.C.for ihis reason PERMIT ISSUING FEE S �Q ��"Q ` z i
Date: �� • • • •�
Signature TOTAL FEE 7 �
OWNER-BUILDER DECLARATION PLAN CHECK APFLICANT I • •7 G.�I S
I hereby offirm ihat I am exempt from the Confrodor's License � � � �7�.,$U
Law for ihe following reason(SeUion 7031.5, B�siness and NAME �
Professions Code): � '
❑ I, os owner of the property, or my employees wilh AD�RESS . �D.�L��8 7
wages as iheir sole compensa�ion,will do Ihe work and CiTY TEL NO. �
the structure is not intended or offered for sole(Setlion
7044,Business and Professions CodeJ. � ��
OWNER
❑ I,os owner of fhe property,am exclusively contracting
with licensed contractors lo construd the projetl(Seo N'p'�� � �
fion 7044,Business and Profession5 Code). ADDRE55 � Q.r � .
CONSTRUCTION LENDING AGENCY Cii TEL.r70. �
I hereby affirm Iha7 ihere is o construction lending ogency(or
ihe performance oi the work for which this permit is issued CONTRAC R� - �/� � ► �
�sec.3oe�,c�.e.). .
, AD�RESS J� �.c.ti „ej •. ' . .
Lender's Name
UTY � � TEL.NO. �� C�� .. _ . . . _
Lender's Address
I certif �ha�I have reod ihts o limtion and srate that the SiniE ^ [y uC. ,o
. y pp LICENSENO.o� /y C1A55 � (.i"�Z
above information is correct.I agree fo comply with all Counly
ordinances and S�ate lows reloting to building construciion, . , ,
ond hereby authorize represenlolives of�his County to enter � � �
on the obove-menroned properry for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�--,.-r.-t-�- �'G-/r.--� �
S�9�aru�e of Appliconr or Agenr �o�e � � � � � �
� �� ° '' �' �iNSPECioR'S NOTES OWNER-FiUILDER DECLARATION
. ' I , _ _`. . �. i
-�i_ - � 'I hcrc6y'aff�Tm'thcl I am ezempt,from iFie Conlractor's
,..... , .... .. -�.,- ;,,.., ,. .
� 1�, )';� ��: ,i -, � . .. . .. . .. . .
..'_-____"' '.._..._..._......_ __. ..,. . .
License Law for ihe following repsan ($eclia� 7031.5,
� -� "'� -� "' " '�"'-"� � - ' ""'-"-" "� �'� � -� �- ' ' � HusinessandFro(erslonsCode):Anycityorcoontywhich
'��'�,-�'•, ,., �` � � reqWres o permi��lo censfrucl,allec(mprove,domolish.
� - � - - � - � � � � or ropelr�ony aMVdure.prior fo/ts lssuonce, ofso ro-
,
'i\ `,.: `-i :,_�� `..., , �. ., ' . . . . . ��.'•, quireslheapplimnllorsuchpermltlo}ileaslgnedsfafc-
�- ��. , , \ - "�;; � ' menf}haf he Is licensed pursvont to}he provlslons ol the
_ ,1� '+.�_'.� � . '� .. . - � � Confrecfor"s Llccnse Law(Chop�er 9(commenUng wlfh
� � �� � � � � � � �� � � - - - � � Sec�ion 7000)of Divis�on 3 0�fhe Susiness and Profes�
- �. . ' . ' sions Code)or fhot he Is exempt therefrom and�he basls
� � � - � � � � . for thc ❑I(eg^d exemp�ion. hny�violallon�o� Secfion
' . ....-- '-._.. .. ; ___. . . . _ .� . � 7031.5 hy any applimnt lor�a permit subjects tfie appli-
' � • . � - - - - � cont fo a civ71 penohy.af nof more�hon/(ve hundred
� �- -- � - --" . -. .. - � -- � - -� � , dollars(5500J.:
,_.. .. .__. . _ ..� . � - - ..- . - � ❑I,as owner of thc properly will do�ihe work,and
. .., - . � • , . - -�he slrucWre�is nbt iNended or offered for sa�e. �.
- �- '-' --� - --' - � - (Sec.7044,Business and Protessions Code: ihe Controo
� . ' � tor"s Ciccnse Law docs not eppfy ro an owner of property
� w6o 6ui(ds or improves fhereon,,ond who does svch
; _ . , �i - work himsef(provided fhol sucb Impravemrnls are no�
� � ' inlendnd or olfered(or safe.11,howcver,fhe building or
, - � �� improvemen�is sofd wllhin one year ol compleficn,��he
� �- � � - � ' �owner-builder wtl!hove the 6urden o!proving fhof he did
- � .- - -, noi butld or lmprove for 1he pvrposc'ol sole.J
. .�s . ... . � � � . �� �
� . .. . . �,❑I,as owner of tho property,om exdusively con-
� tr�cting with licensed ceniroaors to�condtrucf 1he projeci
� , .(Sec 70dd)6us(ness ond Professlonc Code:ihe Confroc-
� . _ � � ' lor i ticense Law does noT opply lo v6o.Jnrr o/properfy
, ' ' ' who builds or Improves thereon,ond who confrocis Ior
� � - � � such profects wltfi a confractor(s)licensed pwsuont fo
'�' � �. � �' � - � }he Confrocfor's Licerse Law). ' ' � '
• � e e • k' . ' ._ ',1 � . - __ . , .. . .. .
� � � � a � � ' - I om exempt vndcr Sec '
-� _ �.�,a��. �- B&P.C.for ihis reasvn
� ' � � � � - � '� i
�-` -- -_ .._.... _.
' ' Date ' . ' .
- �. Owner
'. .. - _ _ , • .. . . �
, , . , i ,
INSPECTOR'SNO7E5 �� - ' - � � �
'\- .��`_ .. \,- .... .