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Home My WebLink About1367A WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT � � I hereby affirm t t 1 hove o certificote of consent fo self insure,or i imre of Workers'Compensation Insuronce, �6A364C HEATING - VENTILATING - AIR CONDITIONING �'�/?i o,a�e.��iled�oPy�ha,aol{Sa�.3900,Lab.C.y c�-eie�eev.iaiai� P❑ollcy No. Company � Certified copy is he�eby furnlshed. COUNTY OF l0S ANGELES BUILDING AND SAFETY � Certified copy is fi�ed with ihe county building inspec- FOR APPLICANT TO FILL IN BUILDING � tion deparfinenf. AQDRESS � - (� �., (PRINT OR TYPE ONLV) Dote z�� Applicant '�� -��'�-- ' LOCALI7Y � NO. TYPE OF APPLIANCE DR EQUIPMENT FEE CERTIPICATE bP EXEMPTION FROM WORKERS' NeaaeSi } COMPENSATION INSURANCE � ce055 Si.��'J�J (This�eotion n�ed not 6�eomploted if fho work Involved by ABSORPTION UNIT,BTU DISTRICi NO. PROCESSED BY the permit Is for one hundred doliarc(5700)or less.) q�R HANDLING UNIT,CFM !d � I cartify that in�he performance of the work for which this permit is issued,I ahall noi employ any person in any manner BOitER,BTu so as to become suble�r}o the Workers`Compensation LOWS. APPROVAlS onre iNs CTOR'S SIGNATURE Da�e�l��opplic6nl� i�7�-1,� �a�C-• I COMPRESSOR,BTU�/ � (O � ROUGH 7/g Y �710E TO APP�ICANT: If, ofter making Ihis Certifimte of VENTItAT�ON SYSTEM FINAL . J�, � d'S nption, you should become subject to fhe Workers' � �.,mpenwtion provisions of the La6or Code,you must forth- EVAPORATIVE COOLER � VALIDATION . ' with comply with suth provisions or ihis permit shp�l be deemedrevoked. . fL�RCe: . Fqu e� GgnviT �d � LICENSED CONTRAQORS DECIARATION _(n I hereby affirm ihai�am licensed under provisions of Chapter 9 HEATER: SUSPENOED UNIT_ �(commencing with Section 7000)of Division 3 of�he Business - w/+« � and Professions Code,and my license is in full force and effect. .. /J .� _ J/! � /S � d �y�,�.��r�^�' � N�..-wcr (Jy✓I�WCe 0 License Number=L�,�/Lic.Clas� � , � V Confratror��j d��.re �L�"'�`S � ❑ I om exempr undar Sec �� 3�•�A � Plan check fee B.BP.C.for this reason� � y PERMIT ISSUING FEE S d #• • • • •8 � Date: Signoture TOTAL FEE �p aj � • •4 6,2 5 OWNER-BUILDER DECLARATION PtAN CHECK APPIICANT • • �4 6 2 5 c=i , I hereby offirm Ihot I am exempt from the Controdoi s License . 4aw for�he following reason(Section�031.5, Business ond NAME . , O 7,� C)'-8 J� � /^P—ro�fessioss Code): . '' 1 I, as owner of ihe properfy, or my employees with . ADORESS - wages as�heir sole campensotion,will do�he work and ' the siructure is not intended oi offered for sale(Section CI7V TEL.N0. 7044,Business and-Prafessions Code�. � OOWNER I,as owner of}he property,om exclusively conlracting with licensed comracfors lo consiruct 1he projec�(Seo- �^�� . � tio�7644,Business and Professions Code). ADDRE55 � CONSTRUCTION LENDING AGENCY � CiiY r �"� TEL. .G�' '7.. t . I heraby affirm ihat thare is o conslruction lending ogency for , �rhe performonce of the work for which Ihis permit is issued CDNTRACTOR � (Sec.3097,Civ.C.). � � - ADDRE55 � '� � S� � Lender's Name CITV ` TEL.NO.+�� l Lender's Address 1 certif thal I v eod ihis a limtion and state thot the STATE � LIC. G y pp LICENSE NO. QA55 - obov formaY s orred.I agree fo comply with all County ordi n e laws relatin9 to building construction, . . � � an h a � ize represen�atives of this Couniy�o enter � - � n o entioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGIIAGE Z'��`�� Signoture of Applicont or Agenl Date . ' � ECTOR'S NaTES OWNER-GUILDER DE��ON � . � I hereby affirm tho�I am exempt from the Conimctor's � " License Law for Ihe following reasan (Settion 7031.5, �,� �� -�� - �� . � � Busirtess and Fro/essions Codej:Any ciiy or county whith . � - � • � � � , requires a permit�o mrtstroct,olter,improve,demolish, � � � or repolr any atructore, prior to its issuance, also re- . - � , .. � . � qo(res th�applicant far such permlrio flle v signed stale� � . „ - � � menl lhat he ls licensed pursuon�to Ihe provisions of Ifie � � � . - Con�ractofs License Law(Ghapic-r 9(mmmencing wlih � � � , � � � Secfion 7000}of Division 3 0l}he Buslness and Proles- � � sions�Code)or that he is ezempt tFerefrom and f6e basis � . ' � ' lor fhe olleged exemption. Any violotion oi Section . . . . , � 703L5 by any applican�/or a permi�subjects the appli- . - cont�o c Nvll pertalty of no�more than five hundred . � � � � . dolfars(5500).: � � . � � � ' �� ❑I,os awnar of rhe property wlll�do Ihe work,and . ,.� - Ihe strudure is no�intended or ofFered for sa�e. � � -� � � � _ (Sec.7044,8usiness and Professions Code: The C�'-ao- � . " ter's License Caw does not apply}o cn owner af p. _drfy - � who 6uflds or.improves fhereon, ond wRo does such . . ark himself provided tha>such improvements ore no� �� infended or olfered for scfe.If,howover,fhe bullding ar � improvemenT is sofd withJn cne year o/completfan,the , owner-6uildar will have fhe burden of proWng thot he did � � not build or improve lor ibe purpose of safe.) . ' . ❑I,os ownar�df iMprcrparty,am exdusively mn- � rracting with licensed tontradors to constr�cr rhe projecr - ;Sec.7044)6usiness and Profassions Codc:The Coniroc- tor's License Law does no�apply to an own��of properfy who builds or fmprove,tFereon,ond who confr¢ds for , � ' - such projects with a tontracfor(s)licensed pursuaM to ,. . , , , � Ihe Controc/or's License Law). � , - I am exempt under Sec. - 8 8 P.C.for fhis reason � � � ' . , � Date Ownar INSPECTOR'S NOTES