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Home My WebLink About1441A _ � WORKE�S'COMPENSATION DECLARATION APPLICATION FOR PERfYIIT � I hereby aff'am ihat 1 have a ceriifica�e of consent ro self insure,'br o ceitificate of Workers'Compensation Insurante, 7eA�� HEATING - VENTIIATING • AIR CONDITIONING or a certified mpy ihereof(Sec.3800,Lab.C.) . Qcyn�20786$7 ComF,a�y St. Furxl CE-818(REV.10/81) Certified copy is hereby fumish . COUNTY OF LOS ANGElES BUILDING AND SAFETY �. Certified copy is filed with iha o building inspec- � FOR APPLICANT TO FILL IN BUIIDING p rt ent. (pRINT OR TYPE ONLY) ADDRE55 �j Da�e Applicant � �� LOCAUTY Wd�.IIUt NO, TYPE OF APPLIANCE OR EQUIPMENT � FEE CER71F ATE OF EXEMP710N FROM WOR RS NEAREST COMPENSATION INSURANCE CROSS SL � (Thi�uofion naad not 6e comptNsd I(ths work ved by ABSORPTION UNIT,B7U pisruicr No. veocesseo ev fhe parmff Is for one hundred dollar�(s100)or lesi.) qIR HANDLING IINIT,CfM �q I certify that in Ihe performance of the work for which fhis .` permit is iss�ed,I sholl nof employ ony persan in any manner BOILER,BTU so as ro become s�bject�o the Workers'Compensation LpWS. n APCROVALS onre uvsvecroe�s SicNnTuee Dofe opplicani � 1 COMPRESSOR,BTU �V ROUGH NOTICE TO APPLICANT: If, ofter making ihis Cer�ificafe af VEN7ILATION SYSTEM FINAL ^t�� Exemption, you shoold become subjeU ro the Workers' � Compensation pro�isions of ihe Labor Code,you musl forfh- EVAPORATIVE CpOLER VA41DA710N wilh comply with such provisions or this permi� sholl 6e deemed revoked. FURNACE: f�lr.QQ.QGRnViTv �11 � LICENSED CONTRACTORS DECLARATION FLOOR BTU V I h¢reby affirm thaf I am licensed under provi5ions of Chopter 9 HEAiER�. SUSPENDED UNIT� . �(commencing wifh SeUion 7000)of Division 3 of the Business � WA�� and Professions Cade,and my license is In full force and effed. � y License Number 475226 lic.Class �''Z� , V co„o-a��o, IIiv. ma. oa,a 8/9/88 .: 1 !�!� 1 A � � � � o . . .� *- I am ezempl under Sec. �`� �� Plan check fee y B.BP.C.for ih�s reason pERMIT ISSUING FEE$ I m �.[,S r. � Dafe: - sig�arure TOTAL PEE ` " `�`�� OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT C'S, � C—�. I hereby affirm that I om exempt from the Contractor's License , Law for ihe following ieason(Section 7031.5, Business and NAME � Professions Code): . ❑ I, as owner of fhe property, or my emplayees with /+DDRE55 � - wages os thei�sole compensation,will do the work and � the struc�ure is nof intended or offered for sale(Section CiTY . iei.NO. , 7044,Business and Professions Code). � OWNER �an� ❑ 1,as owner af fhe properfy,om exdusively conirading with licensed confracrors to canstruc�the projed(Seo MAR � fion 7044,8usiness and Professions Code). AODRESS $$rj �addIilS OV0 CONSTRUCTION LENDING AGENCY CI7Y TE�."�$95-2591 � I hereby affirm that there is a construction lending ogency 4or the performonce of the work for which this permii is iss�ed con,reacroa�vironmental �#f�� t�11# Engi Rting (Sec.3097,Civ.C.). � - ADDRESS 601 N. P 13T � lender's Name CITY TEL,�_82$1 _�� Lenderi Addrass I certif lhat ove reod this a licotion and state Ihal the STA7E LIC C,20 y pp uc�r,se n,o. 475226 CLA55 above infor oti n is rorrect,I agree to comply with all CouMy ordinances and fe lows relpting�o building construction, and ere a �e representatives of Ihis Co�nty to eNer - - upo he m �d property for inspectian purpases. SEE REVERSE FOR EXPLANATORY LANGUAGE 8/9/88 Signatura of Applicont or Ag n Do1e - ' � . ' 1 ETOR'S q6 OWNER-BUILDER DECLARATIOIV � I hereby offirm that I om ezempt from the Contractar's � � � License Low'for the following reason (Sxtian 7031.5, ' - � � � � B�siness and Professrons Code):Any ciTy or coumy which � reqWres o pormi�ro consfruci,olter,improve,demopsh, , � or repair any strucfure, prior to Its issuance, afso re- . quirei ihe applicanf lo�such permit�fo fi(e a slgned stote- � � - � � monf�hat he h I�censad pursvant fo fhe provisions of fhe Coniroctor's Licenso Law lChapfer 9(commencing wi�h �� Section 7000)of Division 3 of fhe Business ahd Pro(es- � sivns Code)or that he is exempt iherefrom and fAe 6asls , � (or �he olleged exemption. Any violoiion af Sedion . . . . . 7031.5 by any oppllccM for a permN so6jecis ihe appli- . � � - cant fo a civil penalty of not more than 7We.hundred - - . � � dolfors(SSOOj.: � � � [!,os owner of ihe property wlll do Ihe work,and � . - �he siruclure is not inlended or offered for sale. -� - (Sec JOM,Businsss and Professians Codc: ihe Cont�ac- � ` . ror's Cicense Law does not appl y to on owner of proper}y � � who builds or improves fhereon, and who does such ' - � � . . work himself provided fhof sucM improvemenfs o-re nat � � - intended or affered lor safe.H,howevcr,fhe 6uilding or . improvsmenl is sofd wl�fiin one year o(completlon,tFe � owner-bullder wiU have fHa burden of proving that he did not 6uild or lmprove 1or ihe purpose of sole.) � ❑I,as owne�of ihe property,am exdusively con- iraUing wi�h licensed contradors to construct the praject - � (Se:.7044)Bus(ness and Professions Code:ihe Coniroc- , . -tor's Li<ense Low does nof apply to an owner of properfy - who builds or improves thereon.and wha contracts for such projeUs with v contracfor(s)licensed pursuonf lo � � - tfie Canfrocfor's Llcense LowJ. I am exempt under Sec. � � B&P.C.for this reason Date . . � � � Owner INSPECTOR'S NOTES