HomeMy WebLinkAbout1194A (5) WORKERS'COMPENSATION DECLARATION \
I hereby affirm �ha�I hove a certiRco�e of�a�,e�,�o,e�f - APPLICATION FOR PERMIT
insore,or o cerfificate of Workers'comPen:mion��wra��e, ���c � HEATING - VENTILATING - AIR CONDITIONING
or a certi e�d�c/op(,y�ih`e,,�reof(Sec.3800,L .C.) • ` CE-818(REV.10�87) �
Q�Y o•"�°'l�1 Company ` � .
Certified topy is here6y f�rnished. COUN7Y OF LOS ANGElES BUICDING AND SAFE7Y
� Certified mpy is filed with the �y build�n9 ins - FOR APPLICAN7 TO FILL IN BUILD7NG � �� n��OS
tion deparfinent (PRINT OR TYPE ONLYJ ' ADDRE55 ��
�Date ^�Applicant?�' +n� tOCAuir GND
NO. TYPE OF APPUANCE OR EQUIPMEN7� FEE
CERTIFICATE OF EXEMPTION fR WORKERS' NeaRcST I�f �
- COMPENSATION INSURANCE CROSS ST. /'�'T`—� /([/�✓
(Thlt t�ctlon n��d nof b�complN�d if ffi�work fnvolv�d b� ABSORPTION UNIT,BTU 0151Ri�i NO. PROCESSED BV
fha p�rmif Is for on�hu�dtad dolla�s(=100)or I�ts.� �
I cerfify that in Ihe performonce of the work for which Ihis AIR HANDLING UNIT,CFM �1 .
permi�is issued,I shall no�employ any person in any monner
V
so as to become su6jeU to the Workers'Compensa�ion Laws. BOIIER,BTU AFPROVALS DAtE IN ECTOR'S SIGNATURE
Dote ePP�i�a�� COMPRESSOR,BTII `�`-"-' Q � ROUGH �.
NOiICE TO APMICANT: If, after making ihis Cer�iiicote of y[NTIlAT10N$VSTEM FiNat
� Exemption, you should�become s�bject to the Workers' •-
Compensolion proviiions of 1he Lobor Code,you musi forlh- EVADORATIVE COOIER VALIDA710N
with comply wiih such provisions or this permit shall be
deemecl levoked. FURNACE: FAU G V O __\
LICENSED CONTRACTORS DECLARATION ROOR 6iU (!U
I hereby affirm thot I am licensed under provisions of Chopler 9 SUSPENDED - - UNIi_
HEAiER
'(cammencing with Section 7000)of Division 3 of the Business W/+ll
and Professions Code,ond my license is in iull forre and effecL rr � P � / ` }
License Numb�����/ Lic.Closs ��O � . u , U
r �
Contractor .� ��! �� Date — Q�� �.� � y,4 F p
� ❑ I am exempt�nder Sec." • ' . t~.7
W
Plon check fee � °�i a
B.BP.C.for ihis reason� N
Date:
PERMIT ISSUING FEE S IU T� I • •4$G C �
Signature TOTAL FEE (/� •4���p x
OWNER-BUIIDER DECIARAiION PLAN fHECK AFPUCANi � • •
I hereby affirm Iha1 I am exempt from the Conlrocfor's license ► e&2 6—8 g
Law for the following reoson(Section 7D31.5,Bosiness and NAME t'�� �
Professions Code):
❑ I, os owner of the property, or my employees with ADDRE55 t-��
wages as their sole compensation,will do Ihe work ond � ��T� tEl.NO.
the structure is nol iNended or offered for sale(Section
7044,Business ond Professions Code�, pyyNER �
❑ I,as owner of Ihe propeny,am exdusively mNroctinq � �VG
wi�h licensed contracron to constroU the projeu(Sec- µ411 ' zQ� ��
tion 7D44,Business and Professions Code). ADDRESS
CONSTRUCTION LEN�ING AGENCY � ��Ty 1�� /1 7EL NO.S9 A��
I hereby affirm ihot ihere is a conslruUion lending ogenty for v �� ,
Ihe perfarmonce ol the work Ior which Ihis permif is issued CONTRAQOR ��D .� .T
(Sec.�097,Civ.C.).
� Lender'sNome � ADDRE55 �C.O w ���j , . .. - "
��TY - 2 v5� TE�.No 33 7�5�7
Lender's Address � � � �
STATE LIC. ^�Q
._ I certify thol I hove read this application ond slate Ihat ihe LICENSE NO. � � -ClASS .
above informoiion is correct.I ogree to comply wi�h alI Counry � � �
� ordi���nppfa��y<es ond State laws relaling 10 building tonstruction,
an�bq outhorize represe t ives of t i{ County to eMer � � - � �
n t a6ove-menNon I pr i�fpr' ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
� APPlimnl or Agenl - Da1e• � � ' � ' � � . . .. .
i.
�, � ' . . ; , ' � , .� . . .. ' � . � , . , . � - . . . . .
� � - ��- � • • - • �INSPECTOR'S NOTES � OWNER-BUILDER DECLARATION
- I�hereby affirm thor I om exemp�from�he Controuor's
'`� " � '''I'�"�- .��'' - License Low.for the following reason�(SecNon 7031.5,
, .. .. _. . ..'_'._'__ .".__. . .......__ _' -.. .. . ._ . ..._.. . . _
'� '-'�- ��"'�-'' '� ' ' '��"'-„ .,'"' ' ' ' .,Euslness and Professlons CodaJ:Any cily ar rounty which
' - ,._ , i � � - � requires o perml/fo conslruU,afler;imyrove,demolish,
� - --� - � - - �� " _ - � � �� �� or repalr ony s}roc}vre. prlor�o ils Issuance, also re-
. ' !�'.. , , ' , . . . _ �qui,res Tfie applitont/or such permlf io life v slgnvd sfote�
� -��-- - `-� --- �- - . -- � �� � � menf that he is llcensed pursvvnl to fhe provlslonz of the
..r - -_ ' i i ' .
f ' . .'.'Y'i �'� � � � ' � � Contractor's License taw(CBopter�9(mmmencing wilh
� ...._._._._ .. ._....�._ ....._. .. . .. . .. .... . . : SeUion 7000J of Divis/on 7 0(�he Ousiness and Proles-
� � ' ,� sions Code)or fhaf he is exempf fhcrelrom and fhe basls
; . � ' . .. � - � !or the oqeged exemptlon. Any violotion ol Setlion
. _ _'.. . _ • . _ _ ._ _ __ - _- _'� � '
. 70J1.5 by�6ny appbmnf(or a permit subjcds thc oppli-
� . , . - �� --.- - � '� cant fo a ciNf penolfy of not more ihan live hundred
. _ _ _ . . . ._- -... —--- -� , . . . doflars(S500J.:
� � ' � - -- - �- � ' - ❑I,as owner of rhe proper�y will do the work,ond
�� -� � - �� -� �� � �- � � � � - �� � � � ` the siruUure is-not iMended or offered for sale.- .
�- -- - -�-_ - -- - - - - ��----- � � � (Sec.7044,6us�ness and Prolesslons Code: Tho Contrao
� - , ' � � � , �or's Ucense Low does no�opply to an owner of property
� who buifds or tmproves fhereon, ond wha does,furh
, � ., � � work hlmseN proWded thot such)mprovemen�s ore no�
��- - �� ��`�� � � �ntended or ol(ered for sale.If,however,�he building or
_ .._ _ _. . � �- lmprovemenl is sold wifhln one yearol compleNon,the
- - � �owner-6uflder wtl!have the burden of proving thot he did
. . � .�nol bWfd or improvo for 1he purpose ol sale.J �-
- ' ❑I,.as awner of ihe properly,om exclu.ivcly com
. . . � '�trocting wilh licensed coniroctors to mnstrucl Ihe projecl
- � - -- - - - '.(Sec 7044)Business and Professlons Gode:The Controc-�
� -�or's Llcense Low does nof apply to an-o�wner of proper}y
. . � - - - - - who 6vilds or Improves thereon,and who conhac�s for ,
, . ' � ' ' - � such pro(ecfs wifh a confracfor(s)Ifcensed pursuant lo
, - tbc Confracfor's Llcensc LawJ.�
� � - � I am ezempt under Sec.
'� - B&P.C.for Ihis reoson
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.'._ .. . � . . . _- � � ..._ � ._ Owner . . . . , .
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INSPECTOR'S NOTES � � �
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