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Home My WebLink About1366A WORKERS'COMPENSATIONDECIARATION A�P�ICATION FOR PERMIT ^� / �..� � I hereby affirm thaj I have o certificate of consent to self � insure,or a certiffime of Workers'Compensation i�s�.a��e, ��4C HEATING - VENTIIATING - AIR CONDITIONING ��"� . i� or p tertified copy thereof(Sec.3800,Lab.C.) CE-B18�REV.10/81). � P❑olicy No, Company COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished. �Ce�nfied copy is filed with tbe cou�ry bui�d��g inspec- FOR APPLICANT TO FILL IN BURDING lion deparimenl. (PRINT OR TYPE ONLY� ADORESS � Date�—��—�� APPlicant 1 � LOCALIiY � �. � � NO. TVPE OF APPUANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEARESi - �� COMPENSAiION INSURANCE ' � . CROSS 5T. � � (Thl�secflon nead noT bo wmplotad if}he work involvod 6y Ag50RPilON UNIT,BTU msrxict No. vaocE55eo sv Tha parmit Is for ona hundrad dollars(S700J or lets.) q�R HANDIING UNIT,CFM /Q - I certify that in the performance af the work for which this . permif is issued,I shall not employ pny person.in any manner � so os fo 6ecome subject Io the Workers'Compensation Laws. BOiLER,BTU AGVROVALS � DATE INSVECTOR'S SIGNATURE ��f=.1/' �4/ Pp _��1��Z^V�/Ie�T�� COMPRESSOR,BTU lV ✓4 ROUGH �.9f`P��"� � L_L]C2_.;,L�A licant �(Sl f TP r.l � '� e � „E TO APPLICANT: If, after making ihis�Certifitate of VENTiIATION SYSTEM fINAt �'j, )��C' Exemption, yoo should become subject to �he Workers' Compensation prowisions of,�he Lobor Code,yoo most forih- EVAPORATIVE COOLER VALIDATION with mmply wilh such pravisions or this permii.sholl be � deemed revokecJ. � FURNACE: FAU GaAv1T;�. �u� � ' LICENSED CONTRACTORS DECIARATION F�OOR e7U �'� � I hereby affirm iha�I am li�ensed under provisions of Chapter 9 HEAiER: SUSPENDED UNIT_ � '(commencing with Section 7000)of Division 3 of 1he Business - WALL and Professions Code,and my license is in full force ond effect. / C� / n' License Numbei�� Lia Claas�G . , V Coniractal{�.��JiF�,.Dale �"�� L'1� � �..� 3�1 b A O ❑ . �� • • • •S 1� I am exempt under Sec. W e.aP.c.fo�rh�s reaso� Plan check fee I + •4 9,7 5 y PERMIT ISSUING FEE; �'o • • •4 9,7 5� � Dote: Signawre TOTAL fEE 0 7,� (�..$,rj OWNER-BUILDER DECLARATION PLAN CHECK A7PLICANT ..-- I hereby af4irm that I om exempt from ihe Conlracror's License . , � Low for the following reason(Secfion 7031.5, Business and NAME '��' � � - /^�fessions Code): - ,—i I, as owner of ihe ro er ADDRE55 �'� . p p fy, or my employees with �wages as�heir sole compensation,will do the wark and CITY ^ TEL NO. � the sirucfure is nof inlended or offered for sole(Sec�ion "' 7044,Business and Professions Code). � � � OWNER� ❑ I,as owner o4 the properfy,om exdusively confwcting � with licensed contractors ro construct the project(Sec- MAIt tion 7044,Business and Professions Code). � , ADDRE55 1q � CONSTRUCTION LENDING AGENCY Q7V 7 .'NO.�"�' I hereby offirm fha�there is o consiruction lending ogency for , 1he performance af ihe work for which ihis permif is issued CONiRACTOR n � (Sec 3W7,Civ.C.). � - . � � ADDRE55 2 � ^' Lender's Name - . . CITY TEL.NO.�r Lender's Address STATE LIC. �y�7-� � I certify that I hav ead Ihis applimtion and slate thot the LICENSE NO. � CLA55 ��G�./ � . a6ove informption correct.I agree lo comply with oll Caunfy or � nce and te laws relating�o building conshudion, � _ � er au� ize represe��ofives of this County to enfer � . . bov i entioned propeny for inspeaion purposes. SEE REVERSE FOR EXPLANATORY tANGUAGE 7-1�� Signo ur of App�cont or Agent Do1e � - IN tEC 6R"5 0765 OWNER-EUICDER DECLAR�:TtON , I hereby affirm that I om cxempt from the Conirador's � . License Law for the followin� re n (Secl/on 703L5, �� - � � - � BusinessandProlessronsCode;:Anycifyorcountywhich � _ � , � . - requfres o permil to consfrucf,aHer,�improve,demolish, . , � � � � or repair any sirudure,prlor fo Ih issuance, also re- - ' � ' " . � . qotrss the oppOcanT forsucb pe�mi�to file o slgned stale- � � � � � ' - � � mertt Ihot he B Ifcensed pursuam to the provisions of the � � � � � Confrador's License Law(Chapter 9(mmmencing wifh . � ' � �- � � - Sec}ion 700D)af Division 3 of thc Business and Proles- '. � - �sions CodeJ or that he is exempt�hcrefrom ond fhe basis � ' � ,. . ' for the ofleged exemption. Any violaiion of Section . � . 7031.5 by any bpplitanl for o permif subjects the appli- . � � .mnt to a civil penahy of nof more�hon 17ve hundred � - � �� . doflors(Y500J.: � ' � - � ❑I,;os p�n�ner of the property will do fhe vrork,and � � � - � . . the siructure is nol intended or o7fcred for sale. � - � � � � � - � � {Sec 7054,8usiness and Proiassions Codr: The_ ,irao � tor's L7cense Caw does nat apply to an owner of properfy � who bullds or imp�oves fhereon, and who does sach - . . work himself prov"rded ffiai sucfi improvemen�s are no� � � � � intended or oHered(or sale.If,howevcr,the 6utlding or � � . Improvemenf is sofd with7n one year oi complstion,tho � � owner-6u'rlder wlll hava�he burden of proving that he did . , . . not bulld or improve/or the purpose of svle.) � . - - ' ❑I,os owner of tha propeNy,om exdu5ively con- : � ., ' � , trpcling with licensed mntrectors ta construcl the project _� - ;Sec.70id)Busines9 ond Prolessions Code;ihc CoM�ar � �� . �� tar's License Law does not apply'to an owncr of p�oper�y . , � who builds or Improves therean,ond who toniracts for ' � ' �- � ' sucb pro�ecfs with a controcio�(sf licertsed pursuani to ` � fhe Controdor's Cicenm Low). � ' I am exempt under Sec. � B&P.C.for this reasnn � _ � . . �� Date � . , � .. . .� ' , .� � Owner � . iNSPECTOR'S NOTES