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Home My WebLink About1023A WORKERS'COMPENSATION DECLARATION �APP�ICATION FOR PERMIT � I here6y affirm that I have a certificate of consent to self . insure,or o cert'rfkate of workers'Compensation Insuronce, �fiA364C HEATING - VENTILATING • AIR CONDITIONING or a certified copy thereof(Sec.3800,Lab.C.) . ��/ '-�� CE-818(REV.ID/81) - P❑ol�ity NoVS�L{1�-�-;Company , � Cerrified copy Is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY � Certifiad copy is filed with the coonty boilding inspec- � FOR APPLICANT TO FILI IN� BW�DING /` b I (�. _ .�_ � tion depariment. n/ (PRINT OR TYPE ONLY) ADDRE55 to /� /�Y7) Date��rr�Applicant �� ^�'�S�N . LOCAUTY .hJ . NO. TYPE OF ACGLIANCE OR E�UIPMENT fEE CERTIFICATE OF EXEMPTION FROM WORKERS' . NEARE57 COMPENSATION INSURANCE - CROSS 57. . (This wction nved nof be campletad if fM1e work Involvad by ABSORPTION UNIT,BTU DisraiCr uo. PaoCESSED Bv fhe permit la for one hund�ed dollors(j100)or lass.) � � I cerlify fhot in fhe performance of fhe work for which this A�R HANDLING UNIT,CFM 11 V permit is issued,I shall not employ any person in any manner BOILER,BTU so as to 6ecome subject�o the Woikers'Compensation Laws, navaovais nnre iNsr�c R'SSIGNAiVRE Date applicanf COMPRESSOR,BTU � �' `� 0 o r ROUGH NOTICE TO APPLICANT: If, ofler moking ihis Certificate of VENTItATiON SYSTEM � PINAL � Exemption, you should become subject to fhe Workers' - Compensalion provisions of iFe Lobor Code,you must forth- EVAPORAiIVE COOLER VALIDATION � with comply with such provisions or ihis permit sholl be deemed fevoked. FURNACE: FAU—GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR B7U � � I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPEN�ED Uwi_ � '(commencing with Section 7000)of Division 3 of the Business ' -WA0. . ond Professions Code,and my license is in full force ond effect. . � , p}, License Number�2s"�� l Lic,C�ass� ► � � ' V ��.. �« -a�- s � Controttor_ Date � u ❑ � i om exempt under Sec. Plan check fee H B.&P.C.for ihis reoson� � `�� O 2,.� � Dare: PERMIT ISSUING FEE S 4 .� f'r I�.t�0.5� ? 1 Signarure T07A1 FEE • • s 2 Q 5 Q� OWNER-BUILDER OECLARATION PLAN CHECK APPUCANT . I hereby affirm tha�I am exempt from ihe Contrador's License - , ��C�'—�5 Law for the following reason(Setlion 7031.5, Business and NAME F ,� Professions Code): � ❑ I, as owner of fhe property, or my employees with A��RESS .j ��- wages as their sole compensation,will do the work and� - � the structure is not intended or offered for sale(SeUion QTV �,�` TEL.NO. �7044,Business and Professions Code). � OWNER � M�� . ' ❑ I,os owner of the property,am exclusively coMrocting with licensed controc�ors ro consiruct Ihe project(Ser MRIL tion 7044,8usines5 and Professions Code}. AODRESS � � CONSTRUCTION LENDING AGENCY aiv � TEL.NO. I hereby affirm Ihot there is a consiructian lending ogenty for � � . � ihe performance of the work for which this permit is issued CONTRAC70R � - �` . (Sec.3097,Civ.C.). � � � A�DRE55 � �� . Lender's Name cin N � rei.No.g�S �j l`�C219 �ender's Address C, !� I cerfify thot I hove read lhis applimfion and stafe fhat the ICENSE NO.�ZS�� ` C A55 �l'� � � - �� above�info�ma�ion is correcf.I ogr lo tomply with oll Coun7y . ordinances and i s rel g to building construction, - , � and here6 rize re re atives of ihis County�o enter � � opon -mentio roperty tor Inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �� Signat�re of Applicont or Agen1 Dpte IN PEtT6R`5 NOTES OWNER-6UILDER DECLARATION � . � I hereby�offiim that I om exempr from the Conrracior's - � License Lmv far ihe following reoson (Section 7031.5, �- � � � Buslness ond Pro{essions Codel:Any city or couMy which . � - � . requires o permil to conslruct,olter,improve,demolish, � � � � or repalr ony strudure, prior to its issuonce. ofso re- - � � q+�(res ihe opplrmM for such permfl to file a signed sia�e- � � � ' � - � ment fhat he is Hcensedpursuanl fo fhe provisions o/fhe Gonfrodor's License!cw(Cfiapfer 9(commendng wlih � � � � � Sec�ion 7000)of Division 3 oI ihe Business ond Pro�es- � . sions Codo)ar fhat he is excmp�thereirom and Ihe bosis ' . • (o� fhe olleged e emption. Any violation o/ Settion �� „ , � _ � � � . 7031.5 by any applicont for o permit subjects the oppli- - , - . � cant to a civil penalty ol nol more fhen five hundred ' - � - � , , . � dollvrs(3500).: � - � ❑I,os owner ot ihe property wllf do Ihe work,ond �� - . ihe structure is not in�ended or offered for sale. . � � - � � � (Sec.7044,Business artd Professions Code: The Contrac ' . � . tor's Llcense Law daes nof oppfy to an owner ol properfy - � � �� - who bui(ds or improves fhereon, ond who does such - . work himself provided that sucA improvemenfs ora no/ � , iMended or o(fered for aale.H,however,fhe buildiog or � - � improvement is wld wilhin one year of completion,ihe . ow�ner-6uildrr will hove fhe burden a3 proving that he did - not butld or improve lor ihe purpose of sale.) �� ^ ❑I,es owoer of the prope�ty,am exdusively com ' , � irocting with licensed confractors fo conshucllhe project � � (Sec,,7044)Business and ProTe;sfons Code:7he Confror � � � tor's License Law does not apply to an owne�ol properiy � who builds or improves theraon,and who contracfs fo� i � , � svch projecis witfi a controctor(sJ licensed pursuant to the Coniroctor's Licertse Lawj. I am exempt under Se�. B&P.C.for this reason Date � - . . � ' � . Owner INSPECTORS NOTES