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Home My WebLink About1489A �.,�WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PERMIT � � •llheieby affirm that I have a certifimle of mnsent to self insure,or o cemfica�e ot Workers'Coropensa��o��osorance, �ansbnc HEATING - VENTILATING - AIR CONDIiIONING � ��C �� or a certified copy ihereof(Sec.3800,Lob.C.J � , CE-818(REV.10/Bl) - � � . POolicyNol�lL(110�fI�Company �SdL�YIA�N-� . Certified copy is hereby furn�shed. COUNTY OF LOS ANGELES . BUILDING AND SAFETY � Certified copy is filed with the counry 6uilding insp • FOR APPLICANT TO FILL IN euitoiN� yj_�' D �, fion deparfinent. ADDRE55 � ,S `j�('(Lr Qn .� /.•G+ . (7RINT OR ttPE ONLY) Dafe ��/��7 APPliconf LOCALRY . g. � NO. TYPE OF APPIIANCE OR E�UIPMENT FEE CERTIFICATE OF EXEMPTION FROM WOR ERS' NEARfST COMPENSATION INSURANCE Ck05557. ' (Thii r�ction n�ed not b•eompt�t•d lF�h�work Involv�d by ABSORPTION UNI7,BTV DISTRICi NO. iRpCE55ED BY the pormlt it for ona hundrod dollars({I00)or loss.) ', /O ``� AIR HANDLING UNIT,CFM� I certify�hat in fhe performance of the work for which this � .permit Is issued,�sholl not employ any person in any manner BOILER,BTU so as to became subject to the Workers'Compensation Laws. aopaOVnLS DAiE INSVECIOR'S SIGNATURE Dpte- APPliwnt COMPRESSOR,BTLI ROUGH � NOTICE TO APPLICANT: If, after making ihis Cenificale of VENTILATION SYSTEM FINAL �/�/-$ Exemption, you should become subject fo the Workers' Compensation provisions of fhe labor Code,you musl forlh- EVAPORA7NE COOLER VALIDATION - wifh comply wiih such provisions or this permit shall be deemed revoked. FuaNnce: Fnu_ceavirr LICENSED CONTRACTORS DECLARATION FIOOR BTU I hereby offirm that I om licensed under provisions of Chapfor 9 HEA7ER: SUSPENDED UNiT-� �� (mmmencing with Section 7000)of Drvision 3 of the Business • WALL , ond Professions Code,and my license is in full force ond effect.' � „/ .p v a !� (�(i�.tti p License Num6er ��S�2C' Lic Clpss �/Z'0 � �J CoMrocb � �ate 9'��`�1 7 � � f ► 0 � 1-� I om exempt under Se `� 4 R 9 A w Plan check fee �� . . . .& y e.&P.C.for this reason D ' _ PERMIT ISSUING FEE S (f d � C.•l 5 ? 7 e<�'�,.. 5gnawre TOTAL FEE x � OWNER-BUILDER CIARATION PIAN CHECK APPLICAM •� � � • • °3 L.7 S v I here6y affirm that I om e.em from the Contractor's license , 0 9,1 1 —8 7 Low for the following reason(Section 7031.5, 8usiness and NnME � � Professions Code): � ❑ I, os owner of the property, or my employees wilh ADDRE55 ' � �, wages os Iheir sole mmpensation,will da 1he work and . ��, � � the structure iz not in�ended or offered for saie(Sec�ion Ciiv TEL.NO. � 7044,Business ond Pro(essions Code). - � OWNER Q ❑ I,os owner of the property,am exclusively controtting wilh licensed controctors to construct the project(Sec- pDRE55 �j �j� �� (,l�. � lion 7044,Business and Pro(essions Code). - CONSTRUCiION IENDING AGENCY Oiv 7et.NO. ' I hereby affirm ihat ihere is a conslruction lending agency for r1 q ' the performance of the work for which this permit is issued COMRACTOR 6n kre f� T //'.� (Sec 3097,Civ.C.�. . - . . � ADDRE55 �v �� . - . Lender's Nome CITV 7E1.NO. �73�.� . , , lender's Address , I certif Ihal I have read this a lication and slale ihal the STATE LIC. y pP LICENSE NO. �j CtA55 .. _ . . . above information is correct.I ee io mmply with all County . . ordinonces ond S�ole low ting to building consiruction, � an rehy oWhorize r sentotives oi ihis CooNy lo enter 1 �- - � �- ' -- � - � - '- � u o �he above- e ❑ d pro erry for inspection purposes. -SEE REVERSE FOR EXPLANATORY LANCUAGE '(, . . . . . . _ . . Signat�re of A licanr Agenl Da�e - ' . .-. ' _ . ' - �'�`�� - •INSPECroF'S t�o7E5 OWNER-BUILDER DECLARATION , -� �t�hereby affirm thot I am�exempt�from�Ihe Comrocror's . � �� ' �" ��A� "� license Law for the following reason (Section 703L5. -'"'�� "-"""' ' " �"'-"` "" ""' � '"" -' r� Business and Prolessionz Code):Any cify or counfy which • . � . ? (' C - ��• � requires a permif lo consfrucl,cller,imprpve,"demobsh, � � �- - �._. . _- ...- - --- -'- . . . ' --__ ._,or repvir ony slruttvre.prlor fo Ifs issvanco, also re- p •'� � � " -' ` � . .,. � �' �' � ' ,. �� ,�-. ;_quiros the opplicvnt�or such permrt fo file'e slgnvd stale- � '�� -� � - �� - -�--�"-� -- �- - � - � � � � men�fhof he Is Ilcensedpursuant ro iheproWslons of tfio � � . Conlrotfor's license Law(Chap�er S(commencing wllh '� .... .. .___. .,. . _._. .._,_._.. _._. ..._- .. . . . . . .SecNan 7000J ol Oivision 3 0(Ihe Business ond Proles- � � . ', � iions Code)or�hal he is exempt.�herclrom ond the 6asis j . � '� �, � � - - - - �� ' �� ' ' � for ihc'alleged exemp�ion. Any Nolofion o� SecHon '` � ._ . '. . . . , � � _ _ .:7031.5 6y any applimn�for a permlt,su6jecfs fhe appli- .__ _ ._ .._ . - - - ----� � - -�� - . . j � . . . . �� -. ...-- ---- . - - .� '' . cant fo a civi!penalty.ol,nof more}han Ove hundred , . _ __ . . ... _. ..- ��- - - '- dolfars(5500).: ' ' ' ' � - � -- "� �' � � ❑I,as owner of ihe property will do the work,nnd _ _.___ ._ ..�. _.. _ . . . . � � , .' , '�\�� : '�� . . , ,-�ihe struUure is not intended or.affered for sole. , .. � - - ��• - -- -� - ' --- � - -� � � � � � �� (Sec.7044.Business and Professions Cade: 7he Confroa . � � .!.' • , . . , . .for i L/ccnse!aw docs not epply fo an owner o1 proper}y i, � �� ' ' who bwld: or improves thercon, and who does such . _ � . _ - � work himsefF provided Ihol sucb improvements orc no� , ' - � ' ' infended or oHered(or safo.If,howemr,}he bv7lding or - . -. � � , improvemenr B sofd wllfiin one yeor ol complelion;Ihe � ' - - ' � �' �owner-bu7lder wilf have 1he burden ofproving fhaf hv did . � � � '- � no�buNd or improve for!he pvrpose o1 sale.J � - � � - - - , �. ❑I,as owner of iho property,om oxclusively con- � �, ' . , , '� trocting with licensed tontmctors to construct the project � - - r =,(Snc.-7044)Busfneis�and Proleeslons Codo.The Confroc- ' _ , . -- '��tor's[Iccue Law'iloes�not apply fo an owner of Property � - - - - - - _.who builds or Improvos Ihereon,and who confrac�s for . � ' , . � _ '� such projects wllh a mnlrodor(s)hcensed pvrsuanf fo -- , �tFe Contractor's-L�censr LawJ. � � . . .. . . _'• . � .._ _. . ___ _ _ ; •. i _� ,: .� .. .. . ' ' � ,. . . _.__ '-_...'._ .� � i � � � I am exempl��nder Sec. _. - � � B 8 P.C.for this reason �� ' - - -,� l � -- : Datc - .. . . . � � ` , ..�� . � . . . . , .. � Owner ' . . - .- -' .-. '=�- - --- � -- ..__._--� ' �� - ' . . -. " . . . . . . . - INSPECTOR'S NOTES _ _ , � � ,