The URL can be used to link to this page

Home My WebLink About1660A _. i _ �� WORKERS'COMPENSATION DECLARATION � APPLICA 1 ION FOR PGRM�IT � i hereby affhm tha� I have a certifim�e of consent lo self , - insure,or a certifimre of Workers'Compensmion Insuronce, HEATING - VENTILATING - AIR, CONDITIONING or a ceriified capy thereof(Set.3800,Lob.C.) 76n364C . . CE-818(REV.10/SI) P❑ollcy No. Company � Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY � Certified copy is filed wirh the counry bu�lding inspeo- FOR APPLICANT TO FILL IN BUILDING.�/ / �� tion department. (PRINT OR TYPE ONLV) ADDRESS Ic7 k� GV Date Applicant . � LOCALiTY�/�(,/L�7" NO. TYPE OF APPLIANCE OR EqUIPMEM - FEE - CERTIFICATE OF EXEMPTION FROM WORKERY � NEARE57�q p`�� COMPENSATION INSURANCE - CROSS ST �'\ (This tection naed nof bc aomptafod ff fho work Invalwd by � ABSORPTION UNI7,BTU oisreia No. ve ESSEO BY }hs permH ts for one hundred dollars({100)or less.) � qiR HANDLING UNiT,CFM a`U �� I tertify fhat in fhe performance of ihe work for which ihis � � �7 permit is issued,I shall not employ any pe�son in any manner � gOaeR,BTU so as to become subjecl to ihe Workers'Compeosqtion laws. naPROVALs onTe iNsvEcroa�s sicNnruxe Date Applicant COMPRESSOR,BTU ROUGH NOTICE TO APPIICANT: If, ofter moking this Ceriificate of VENTIL4TION SYSTEM FINAL Exemption, you should become subject to 1he Workers' Compensafion provisions of the labor Code,you must forth-' EVAPORATIVE COOLER VALIDATION with comply with suth provisions or this permit shall be �/ .j��S 'ee� 6��p, deemed revoked. FURNACE: FAU_GRAVITY y�� `,Y s��G �LICENSED CONTRACTORS DECLARATION FLOOR 6TU � #� • • • •fj - I hereby affirm that I am licensed under provisions of Chapfer 9 HEA7ER: SUSPENDED UNI7__ �� 'commencin with Section 7000 of Division 3 of the Business wA�� and Professions Code,and my license is in full forte and effec�. � � • •2�'5� � •�. License Number Lic.Gloss � � � • • •2�.�5�'= V G' Contracto� �ate , 0 1,0 2—8 7 � ❑ I am exempt under Sec. w Plan check fee d B.BP.C.for this reason� � N PERMIT ISSUING FEE S � � oaie: TOTAL FEE 3� Signoture � OWNER-BUILDER DECLARATION PIAN CHECK APPLICANT , I hereby affirm thot I om exempt from the Confractor's License � � � Low for the following reason(Section 7031.5, Business pnd NAME��,��'j�� R, . �� P�ofessions Code): � �1 J� I, as owner of the properly, or my employees with AODRESS� /�' �{3/�7 S 7-�L V � . wages as their sole compensation,will do�he work and CITV TEL.N ��r } the structure is no�infended or offered for sale(Section �' �.�•G C . �j�-ZS � 7044,Business and Prpfessions Cade). . ' OWNER sf�� f ❑ I,as owner of the property,om exclusively contmcting MAIL �, with licensed contractors to construct the project�Seo- ADDRESS � tion 7044,Business�and Professions Code). CONSTRUCTION LEN�ING AGENCY CI7Y - TEL.NO. I hereby affi�m ihat ihere is a consiruc�ion lending agency for � � � the performance of the wark for which this permit is issued CONTRACTOR (Sec.3097,Civ.C.). . � . . . . . . . . ADDRE55 � �� Lender's Name CITV . TEI.N . . . Lender's Address � STATE LIC. I certify Ihat I have�ead fhis application ond stote that the LICENSE NO. CLA55 � � - ' above information is correU.I agree to comply with all County � ordinances and Sta�e lows relating to boilding constroction, - . , . _. . ond hereby authorize represenfatives of this County fo enter � upon t e aboy�- ntigqe Proper�y for i�spec�n p�^o,ses. SEE REVERSE FOR EXPLANATORV LANGUAGE P�� Signoture of Applimm or Agen� Date � � , 1�15PECTOR'S NOTES �WNER-BUILDER DECLARATION � . 1 hereby affirm iha7 1 am exempt from ihe Contratlor's , � - '� License law for the following reason (Se<tion 7031.5, � � � ' - �� " � �� ` Bus'rness ond Professions Codej:Any city or counfy which � . .� � requlres a permH ro conitruct,olfer,Improve,demolish, � . � ____ or repair any struclure, pr(or to i�s issuance, also re� � � .quires}he applicant for s�ch permi�to flle a slgned stote- � - � � ment lhoi he is Jitensed pursuant to the proWslons of the - � .. � Confrodor's License Law(Chapter 9(commencing wlth ' . � �� - � � - Settion 7000)of Divisian 3 of the 8usiness and Profes- � �sions Coda)or that bv is exempt therefrom and the basis � �� for ihe alleged exomption. Any viofafion o/Sec/(on � . � � - � 7031.5 by any applican)(or a permN sub�eds The appli- � cant to a civil penalfy of noi morc fhan live hundred � -�- � � dollars(5500).: � � ' ❑I,as owner of the property will do ihe work,and �� the siructore is nat intended or offered for sale. � �� - � � � (Sec.7044,Bvsiness and Professions Code: The Conirae � . � . . tor's litense Law does noi vpply lo an owncr o(propeNy � �. j �. . - � � wha 6uilds or improves tbereoq.and v�ho does suth �-� � � ' ... work himseH provido-d fhot such improvemenis ase not � � - � .� Infended or oflered 1or sale.If,however,ihe building or �.� � ' impcovemenl is sold within one year of compl¢tiop,tire , � _ � � -owner-builder will have thc 6urden o(proving fhot he did - � � noi 6WId or Improve for ihe purposo of sale.) � � �� , � . • ❑ I,as owner of the property,om exdusively con- � � � tracting with lirensed coniractors to construct ihe project . . — - , . (Se c.7044)8usiness and Professlans Code�The Contrac- � for's License Law does na!apply lo an owner of propeNy � who buifds or improves fhereon,ond wbo contracfs lor � � sutb projects wiih a con}rocfor(s)licensed pursuanf io ' � � the CoMractor i license LawJ. � I am exempt under Sec. � � � B 8 P.C.for ihis reason Date Owner INSPECTOR'S NOTES