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Home My WebLink About1832A 6384A WORKERS'COMPENSATION DECLARATION � � �e offkm that I have a certificate af consen�to self APPLICATION FOR PERMIT s ,or a ce.iificate oi Workers'Compe�souon Insorance, �bA364C HEATING - VENTILATING - AIR CONDITIONING a cerufied topy�hereof(Sec.3800,Lab.C.J . . � _ ) �1 CE-81�REV.10/81) - - POolicy No.��1�{ompany -S��//E Clfhl�-�`'1�lu�!J� � � Certified topy is hereby furnished. C O U N T Y O f L O S A N G E L E$ B U I L D I N G A N D S A F E T Y Certified mpy is filed wifh Ihe county building inspec- � � FOR APPLICANT TO FILL IN Bu4DwG '�?I- Z . BR�- �,�,yry �i ion deportment. n�oeess � '� 'n J � ��J (PRINT OR TYPE ONIY) � IOCAUTY ate b Applitant 7�V r� �n;�_^ [ NO. TYPE OF APPLIANCE OR EOUIPMENT . FEE J /� CERTIFICATE OF EXEMPTION FROM WORKERS' NEnzESi CO L 1 �7 � COMPENSATION INSURANCE CROSS Si. (Th(s s�ctlon nwd not ba compl�}ed if fho work involvod 6y ABSOFPTIDN UNIT,BTU DISIRiCi NO. PROC 5ED BY fhe p�rmif fs for one h�ndred dollors(5700)or lose.J AIR HANDIING UNIT,CFM � I terfify Ihot in Ihe performance of the work for which this permil fs issued,I sholl no�employ ony person in any manner . so as to bemme subject io the Workers'Compensalion laws. BOiLER.BTU ACPROVAL$ 'DAiE INSPECfOR' SIGNATIIRE Dafe 6PPlicanl - �COMPRESSOR,BTU ROUGH ' N0710E TO APPLICANT: If, after moking this Certifico7e of �VENTIIATiON SYSTFM FINAL � �� ` Exemption, you should become subject �o Ihe Workers'. Compensation provisions of Ihe lobor Code,y0o mo5f f0�ih- EVAPOFATIVE COOLER VALIDATION with comply with sucb provisions or lhis permit shall be� - � . � �- Claemed levoked. ' ' - fl1RNACE: fAU_GRAVRY ' ' LICENSED CONTRACTORS DECLARATION fi00e BTu I here6y affirm thaf I am licensed under provisions of Chopler 9 NEATER: SUSPENDED UNIi_ • . -_� �?'1 F; '(commencing with$ectian 7000)of Divislon 3 of ihe Business � `r/A�� . � and Professions Code,and my licensa is in lull forte ond effed. �•6M M� C�AL 1�O f1 ^ e(� f;• � �•2 2 d l5 37;6 G�f' .� , . 1 �. ' o License Number Lic.C�ass �/,rt/ M�x!'1�Qf/�� ► ,I � � .� �' � a /( / � [V /I!fC Coniractor .fi�w� � �Ji 5 Dale /2�' � - •i• ••� [.)O� � ❑ I om exempt vnder Sec. � . . � L� �3 2�_��t w Pian check fee � �- w B.Sv.C.for ihis reason pERMIT ISSUING FEE S � Date: 5gno�ure TOTAL FEE • . OWNER-BUILDER DECLARATION P�AN CHECK APP�ICANi � I hereby afii�m ihat I am exempt from the CoMractor's License . ► � Law for the following reason(Secfion 7031.5,Business and NAME . Professians Code): � . � ❑ 1, as owner of the property,�or my employees wifh ADDRE55 � ' � woges as fheir sole compensaiion,will do Ihe wark ond CITY � iEL NO. ' 1he strocture is nat intended or offered for sale(Section � 7044,Basiness and Professions Code). � � - . '=�`J�'.4 Fl OWNER �i K CQ'y I,os owner of fhe properly,am exClusively mntracfing �i� • .!q�r with litensed tontrdctors to construcl 7he projecf'(Seo- MA�� (f�/ �f�• °��'J.�� AODRE55 , , /3 � /Z S• R , . .�.��e� fion 7044.Business and Profescians Code. r CONSTRUCTION LENDING AGENCY CITY u TEL N0.7�C(;�S' � g ' � � I hereby affirm fha�Ihere is a mnstruclion lending agency for ��l.z�l—P Q ihe performance of ihe work for which this permit is issued - , COMRACTOR � , ' Q� .. (Sec.3097.Civ.C.). .- . . . . .. - , '-^�'�— � ADDRESS 1 y `L i �.L . . __ _ . . . . ' � . . lender's Name � Lender's Add�ezs �-. . CiT� E ��'� TEL.NO.� ` . . __ . .. . . . I certify lhot I have reod this applimtion ond slate rhol 1he LICENSE NO.-� .J_�� ( �CLASS � � - � - obove information is correcf.I agree to tomply with all Couny , ordinances and State laws re ting to build�ng tonstruU�on, � . � ond hereby aulhorize repre tofives of fhis Counly fo enter � � � �� . upon the abov nemi ` -perty r inspecrion purpos � , SEE REVERSE FOR E%PLANATORY LANGUAGE _ . _. � . . Sig alure oF Appliconl or Ageni � Date�`� . � � � � .. . .. . . . .. ,. .� .. . .. ' . ,. .� .. '\ • � ' INSPECTOR'S NOTES OWNER-BUIL�ER DECLARATION :; , \ ,. .. . ,„„. . „�, _. . ,_ . , . .......... ' `�heroby otfirm thaf I am exempt irom�the Conrractor's� �' ' � � �� ' -� License Law ior Ihe following raoson (Section 7031.5, . ..._.. . _ '._.'.."_ ._.. ._. _ . ...._�_ .__ _ _ ._ .._ ___._".. ...' .' _. . _ _ . ....... . � _ , 6uslnessandProlezslonsCode):Anycilyorcounlywhich ' . . ' � ' , ' . ' , . �-� � � � � � - �equlres a permn to conslrocf,eller,Improve,demohsh. . -- � - --- - -- � '� , '- - � � ' ��' ' � - or ropalr any etructure, pAor fo Ifs issuoncc,olso rc� ..._ . __ ., ._ /,-,_,'. . . .. ...... .. . � .. . . . . . I � . �`qulres�he opplrcaN for such perrtii�fo file a s`ignod sfaie- . � � � . ment fhot hvJs Ilccnsed pursuanl to thc provisfons of fhc i �' ' ' � . Confratfor's Clcense'law(Cfiapfer 9(co.nmencing wifh i. . � � „__.._.__...._ .._ : _. .... . .. �... , , - . ' ; _ _ � � Section 7000J o�Divislon 3 01 ih6 Eusiness and Profes- i � � � - �sions CodeJ or fhaf he is exempi fhere(rom and the basis � �^ �� for Ihe olleged exempf�on, hny viofafion of Seclion ..� __._ '' . I �� - ,��-'- � ---�� 7031.5 by ony oppUcant tor o permit subjecfs Ihe appli- �,, { - , , . ..:.__. ,_ I - ` cont fo a clvil�penolry ol not,mwe tficn live hundred �__. _ ._-_ _._� . . . . . .- .-- - ---�- , . dollars(SS00J.: � �� -�- � ' ❑I,os ewner of the property will do�he work,and � ..__. _. . __. _ . - . _. �. � � 'Sec.'7044,r6uslness�ocnded oi effcred for sale. : . � � ----� -� -- -- '� -- - - -'- - � - --� � � � ' - ' � ,{ nd Professlons Codc: Thc Contrvo- � . ,,., .,. , . , �for's Llcensc Law does nof opply fo an owner of property . � �- _. , � . who bu7lds or�imprwea fhercon, ond wbo does svcfi - � _. � � . . . � work h(mscf(providcd thot such improvcmenfs orc not � �� iMendod or oflered lor safe,IL Fowover,�he buffding or . , � � • __.. _ _ � , � Improvemenf fs sold wilhin one year ol compfofion,the _ � -- -� - - -- � � -owncr-6ulfder wql hovc fhe burden of proving}haf he did � . � � . � _ _ 1 � , � � _ , : � nof buifd or Improve for ihe purpase o/sale.) � � ' ❑I,as owner of ihe property,am exclusively con- � ' , o , . � - . , � . ..�- �-- rrorting viith Ilccoscd contrcctcrs�to�mnstruct t!�c project - - � � - - �� (Sec.7044)Buslness ond Pfolessions Code:The Conlrac� � + � �, - lor's L�cense Law doee no�oppfy to cn owner of propeny � , � - - who builds or improves ihereon,and who tontrads far ' - � � . `. � � � � � � such projects wtfh a confrocror(s)ficensed pursuan�to � � � � �� - � fhe Conlro[tor's llcrnse Lmv):� ' � � . � _ __� _ . . , . _ . .___ _. ' . . . _. . � . . _ . . .__ . . ._.._. _ ....... . .. ... .. ... . . ' ' _ � � ' I am exempt under Sec. � .. . . . .. . , . .. i. . . . B&P.C.for ihis reason � � � 1 - � �. __ ..__ .... _ .._.._ ...._. .._ .._ . .. _.__._. ._•. . . , ' . - . .. i Datc . . . .., „< z . . . . . . . ... .... . . .. _. _ _ , . . � • ` � - � . _.�_. t� _ ' . . . '� ��.. . . ..:_ Owner � . , . , �. . . ` , . _ _ .. � - ` V•' � ,� � -- ' � - ---- -�. . ' . . �_ _ � � � .. .., . . . . . . � INSPECTOR'S NO7E5 � . �� .. ..- � : ._ .. . . : ... . . . � . .