HomeMy WebLinkAbout1368A WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affifm Ihat I have a certificate of consent to self y �
insure,or o certificote of Workers'Compensation Insuronce, �6A35aC HEATING - VENTILATING - AIR CONDITIONING o`a� '�,�3
or a certi�ed copy thereof(Sec.3800,Lab.G.) .
CE-818(REV.IO/81)
POol�icy No. Company �
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed with the couMy building inspeo- FOR APPLICANT TO FILL IN Bl1�LDING A�„�^ �
�ion dep�artmGent. (PRINt OR TYPE ONLY) ADDRE55 �c.�(►� �
Date����n «J APPlicant-��� LOCAUTY �U'V V �{
NO. TYPE OF APPLIANCE OR EqUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NE4REST `�-,,-.� 1
COMPENSATION WSURANCE Geo555T. �LVI�tiJ �I
(Thia axtion need not ba eomple��d if fhe work involvad by ABSORPTION UNIi,BTU OISTRICT N0. PROCESSE�BY
Ihe permtt ie for one hundrad dollars(5100)or lacs.) q�R HANDLING UNIT,CFM /U
1 certify thot in the performance of tMe work for which thls , �
permii is issued,I shall nof employ any person in ony manner g01lER,BTU
so as to become subjecl�o the Workers'Compenwfian Laws.. �/y�^� nwaovn�s onre INSPE�oa�s sicNnruae
Date J (��ApPlicant�Y,1.�S.�.��f�f^r- / COMPRESSOR,BTU ���L�'� /O �'�+ ROUGH �J/9 �
f'"^TICE TO APPIICANT: If, after making this Cerfificale of VEN7IlATiON SYSTEM FINAL � � �(
� nption, you should 6ecome subject to the Workers'
Compensation pro��sions of�he Labor Code;ya�musf forfh- EVAPORATIVE COOLER VALIDATtON
wi�h comply wilh such prvvisions or �his permit sholl 6e . �
deemed revoked. , FUeNaCe: FAU GR VITV �� � _
UCENSED CONTRACTORS DECIARATION � F�OOe eTU
I here6y affirm ihol I am licensed under pravisions of Chapter 9 HEAIER: SUS7ENDED � UNIT^
�(commencing with Section 7000)of Division 3 of fhe Business - � WALL
and Rofessions Code,ond my license is in full force ond eff8cf. , ''/ ,j . fh¢ L / � p�„
��7 Ns-rct�o frL��(.C.c.C.� O
Litense Number Lic Class C L� , U
�
Coniracto 7e 7/C'� �1 3 6.8 A �
� v
I am exempl under5ec. ���� . � �8 �
Plan check fee
B.&P.C.tor�his reason� �
pe�e, PERMIT ISSUING FEE S 0 S � • '4 4 5 0 �
TOTAL FEE • •4 Q$p�
signa+ure . •
OWNER-BUILDER DECIARATION PLAN CHECK APPIICANT [f�l'� � �7 1 6-8 5
1 hereby affirm ihaf I am exemp�from Ihe Conirpc�or's license . ,
Low for ihe following reason(Section 7031.5, Business and NAME �
�rofessionsCode): -
7 I, as owner of ihe properYy, or my employees with ADORESS
woges as�heir sole compensation,will do the work and -
fhe sfructure is not intended or offered far sale(Section QTY TEL.NO.
7044,Business and.Professions Code). . ,
04VNER
❑ I,ps owner of the properry,am exdusively tonfracting .
with licensed contractors to construc�ihe prajed(Seo- MAit � �� �
fion 7044,Business and Professio�s Code). � ADDRESS �
CONSTRUCTION LENDING AGENCY CITV ." � �- '1 . �(!''1
I hereby affirm thot there is o mnstruction lending agency for � -
the performonce of the work for which ihis permi�is issued �pNTRACTOR -
(Sec.3097,Civ.C.).� 't -.I + .- Q�
- AODRESS Ul/ C%�}i� �J
Lender's Name
CITY . 7EL NO.� r �
Lender i Address
STATE LIC.
I certify thar I h e ad this appiication and state rhat the LICENSE NO. CLP.55 � . �
abo informafi ' correct.I agree fo comply wilh al I Counly � .
or nce n te lows relating to 6uildinq tonstruction, - � , .
a d a rize represenlafives of Ihis County�o enter �
p bo entioned proper�y for inspection purposes. SEE REVERSE POR EXPLANATORY LANGUAGE
���o"t�7
Signoture o4 Appliwnt or Agenl � Dofe � �
A
11i ECTORS NbTES OWNER-6UILDER DECLFiRAT:OiJ
� . ' I hereby affirm thot I am exempt from the Coniractor's
��- License law for. the following reason (Sec�lan 7031.5,
' � �� � -� � � � � Business ond ProSessions Code):Any ciry or munty which
� � � � � � requires a permif to con:truct,ol�er,�mprove,demofish,
� - � � � � or repair any strucfu�e, prfor fo!ts issuanca. also re-
�,� � � . , . qui�es tba opplicanf for sutM1 permit fo(ile a slgned s�ate-
'�� � �� � � � � � maM}ho!he!s lieertsed purs�anf to}he provlslons of the �
� � � � . � � . . Contractor's Llcense Law(ChapTer 9(commenting wifh
,� � �� � - Seciion 7000)o�Divlsion 3 of ihe Business ond Profes-
�� � . . sions CodeJ or tha�he is c�zempt therelrom and the bosis
� � � � ' for tfie alfeged e emption.-Any vialafion o� Section
. .. . , 7031.5 by any oppficqnf ior o pe-mi�subjecis}he oppH-
� � � � cant to a civlf penalfy of not mom tben fWe hundred
- � - � - . dollars(5500J.:
. . � � � � �� ❑I,os owne`of the property wlll do Ihc Work,and
. . , � the stru<ture is not intended or offered for sale.
� - � - � � - � (Sec.7044,Business and Professions Code: ibe(^ 7r
� � . , � � .. !or's Licenso Law does not opply to on owner o(pi..,,erfy
who bulfds or improves thereon, and wha does such
� work himself provlded�hot sucfi improvemenls ore nor
� �� . - infended or oNored lor safe.If,however,the building or
� � improvement is sold wlthin one year oi mmpletion,thc
. owner-butlder will have 4he burden of proving that he did
� � � � . � no�build or Improve for iha purpose of sale.)
� � ❑I,as owner tlf 1Fe property,am exclusively con-
� . � tr6cting with Iicensed mntra<tors ao con,t�uc�rhe p•oject
(Sac 7G44)Busirtess and Professions Code:7hc Confror
� - - tor's License Lcw does no�apply�o an owncr of property
� � who builds or fmproves fhereon,and who con}rods for
� such projects wfth a contrador(s)licensed pursvont lo
� , i ihe CoMrector i License LaviJ.
� � I am exempt under Sec.
� B 8 P.C.for this reason �
' � . ��� � - � . Date �
- Owner
INSPECTBR`S NOTE5