HomeMy WebLinkAbout1730A (10) WORKERS-�oMPENSAT�aN oE«ARAT�oN APPLICATION FOR PERMIT �
1 her'eby affirm thar I have a certifimte of tonseM to self
' s.u{ra,or o certifimte of Workers'Compensatian i�5��a��e, ,bA364� HEATING - VENTfLATING - AIR CONDiT10NING
F7��fl� l"i'"-VI`i°.] 6.C.) .
� Q ' � CE-�Y,10/81)
acy o. Compon r�
Certifled copy is hereby furnished. COUNTY OF l05 ANGElES BUILDING AND SAFETY
� Certified copy is filed w�rh rha co�r,-bu��d��q i�spe�- FOR APPLICANT TO FILL IN aooaess `�'� - t� ���
fion por m n� / (PRINT OR TYPE ONLY)
Date e APPlican . � ""�-` IOCALIiY ��.�L,�� �L
NO. TYPE OF APP�IANCE OR EQUIPMENT FEE -
CER71F ATE OF EX€ 1 FROM WORKERS' NEAREST
� COMPENSAT INSURANCE CROSSST.
ABSORPTION UNIT,8TU DISTRiCi NO. PROCESSEO 9V
(Thii t�cTion n��d not 6�compl�t�d ff tM work lnrolved by
th�p�tmh Is for on+hundrvd dollari(=100)or les�.) I�
I cariify that in the performance of�he work for which ihls A�R HANDLING UNIT,CFM
parmii is issued,I shall not employ any person in any manner BOILER,6TU
so as to become su6ject lo ihe Workers'Compensotion Laws. acoaovnts onrt iNsveaoe•s si�N.aTuze
�I COMPRESSOR,BTU �U � �O � ROUGH
Date %pplicant
NOTICE TO APPLICANT: If, after making this Certificote af VENTILA710N SYSTEM FiNA� �'4F�Gf�
Exemption, you should become subject ro the Workers'
Compensofion provisions of the Labor Code,you mu5f forih- EVAPORATIVE COOLER � VALIDATION
wilh comply wifh such provisions or this permi� shall be
deemed revoked. FURNACE: - FAU- �VITY tl0
IICENSfD CONTRACTORS DECLARATION fIOOR eTU U
I here6y offirm ihat I om licensed under provisions o#Chapter 9 HEATER: SUSPEND[D UNIT_
�(commencing with Sedion 7000)of Division 3 of�he 6osiness wA��
and Professions Code,and my license is in full force and effect. „ . �y
I �!�L 1-,�(.e;� O
License Number lic Class / ' V
f� �
Contractor e � Y` � ;'_� �3,C I'� �
❑ I m xempt under Sec �' E.b � � a 8 �
Plan check fee
.BP.C.far this reason� -
PERMIT ISSUING FEE S Q O I e �-,,2[5 �
oare:
TOTAL FEE ,7+ . e ;, _%5�
Signol�re
OWNER-BUILDER�ECLARATION PIAN CHECK AaPLICANT ���C_�S
I hereby offirm ihat I om ezempt from�he Contwdor's License � ►
Law for the foilowing reason (Section 7031.5, Business ond NAME
Professions Code�: �
❑ I, as owner of the properly, or my employees wifh ADDRE55
wages as iheir sole compensation,will do ihe work and ��TY 7EL NO.
ihe strudu�e is not intended or offered for sale(Sect�ion
7044,BusinessandProfessionsCode). t^y���� `�,q,r( / .
OWNER tA "Gf-T/`• L�1
❑ I,os owner.of ihe property,om eadusively confracting Ma` `� / �/��'
with licensed controdors to consiruct the project(Seo- qDDRE55 C /lY �'/�
tion 7044,Business and Professions CodeJ.
CONSTRUCTION LENDING AGENCY Ci7V �.NO. �
I hereby affirm that there is a construction lend�ng agency for � '}
ihe performance of fhe work for which this permif is issued CONTRACTOR�� �, ' ��(J , �
(Sec 3097,Civ.C.). '`
ADDRE55 (�y.''L �(J I��
Lender's Name �
CITV �+(,,,�,� TEL.NO, � _,
Lender's Address
STATE / LIC. ^
I certify thdt I have reod rhis applicp�ion and state that the IICENSE NO. �q C1A55(�-
dbova information is correct.I agree to comply with oll CauMy �
ordinonces and State laws reloting to building consir�ctlon,
and here 7 a�hor�ze representatives of this Counly to enter
on th o!e- e n ned p. erty for ins crion urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig fure of Applicom or Agent �e
1 tlR'S NO7ES QNfiV_C-EUIL6cl'.C��Ci.F,F;<1TION
� � .I h��ehy affirm thn�I a r from ih.�Controc�o(=.
, Lic�nse Law for rhe followir� reason /Setfion 703L5,
� 8uslness and Prafossions Codc1 Rny cify or county whrch
- requirr;a prrm��b cans'ru;L ollcr,imo:eve,dan;cllsh,
� „ _ r nny sirucluro, prior fo i's Isauancc, olso re-
� . . .quiree f�,�opplic�rvl ler s�ch perrnil7o 7ile c signa,'S7a:e-
men�thct he L-lirnssd pursuon�to t'no provisions of the
Gon'ractor's lica-ww Law(Chq�fcr 9(mmmencing with
� Senio.�700Gj ef D;vi;ion 3 0�thc 5usine,:cnd Profes-
sio
ns Cod�)or rhot i�a L�e;:mp;r',;�r�from and Iha basis
, • � � (or nSe oilo,ycd c rr_p;io i. . ivle3ion of Sec!(on
� - 7031.5 6y cny cp�fi:c�,�r fcr a Ferrr�it subjxls fl,e�eli-
mnt to a civi!pan�;ry o>no�morc than flvo hundred
doUors(SSOC).�
❑�.�s ovinc�of thc propc�ry w�i7 do the work,an.,
� � � th�struc+urc is not inrond-d n.oiiG�c�.d fo;,olr.
(Sec.70ea,Pus�e��ss and Prcfc;sions Code: 7�0�CoNrac�
� . tor's Lfcensa Lcw dees nof cryply to on o�,a-ner of pro�rry
who 6uifo'; c:improves lh�rcon, end vaho deas such
� work himsPff�rovideo'!fiot such im�ravernerNs ore not
_ _ _ in�ended or oif�-o�lor salc�.lf,howwer,Vhe bullding or
� im�rcvam�N Is sold wiihin onw yecr ol corr,p!Nien,fhc
ownerbuild�-w!U hcva fhc burden o�prcving thot he did
� nor build or improue.for i4e Fwr�ss:,of sala.J
�_ ❑I,as owner of ihe property,a exclusively c -
�racting wilh lice+r;ce�d contr-adars ro c.. , c�the project
� ._ �. � (Scc 70a4)Bu:iness ond Pro{es:.lons Codo.�Tho Con�rac
tor�s License Lov�deaas nof epply�e ar:o�nm_.ef prc;ncrty
! ., who builds or improves t1-c�re.��r„end�.°�i;u contracts�or
such projertg uvlfb r conirotfor(sJ licens�d pursuen7 10
thc Conhactor's Liccnsn Lav.•J.
___ I am excsrtipl undnr Sec.___.__
— -- 8&P.C.tor Ihis reac�n_ �_.__
. . . Datc_— --.,—
Owncr
INSPECTOR'S NOTES