HomeMy WebLinkAbout1244A WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PERMIT � �
I here6y aHirm that I have a certifitale o(consent to self .
insure,or a ce�rificate of Workeri Compensation Insorance, 76n36aC HEATING - YENTILATING - AIR CONDITIONING
or a cerfiiied topy hereof S c.3800,Lab. ) , , .
L,,'�7' �F ��8(�jfV.iqi81) .
P❑ollcy Nor t.� �-`Co pony � �rJ i l�t��e�r /�/��1�� � . .
Certified copy is hereby(urnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� CerYfed copy is filed with ihe co nt uild�ng inspeo-' FOR APPLICANT TO FILL IN BUILDING / �/-� /,�'r-(` �
tion departme . (VRIN7 OR 7YFE ONLY� ADDRESS 2��'( �`7 �(�yfY�/IJ
Dale ��Applimnt , ���1 IOCAUTY AL
NO. TVPE OF APPUANCE OR E�UIPMENT� �- � FEE
CERTIFICATE OF EXEMPTION FR M WORKERS NEAREST /. � (_� I
COMPENSATION WSURANCE ,/pz p - r. CROSSSi. c r i
� (This saetlan n�od no}bo eomplefad it fhe work inrolvrd by � A850RPTION UNI7.BTU y�T.`� � C7�J oisrcicr r�o. . vaoeesseo er
the pormit 1�for ono hundred dollars(5100)or Iets.) q�R HANDLING UNIT,CFM � `"� ��
I cenify thm in the performance of the work for which this _
permil is i55ued,I Sholl not employ any person In any manner gOILER,BTU
� so as to become subject to the Workers'Compensafion Laws. acvx0�Ai5 oare INSGECTOR'S SIGNALURE
. Da7e � Applicanf COMPRESSOR,BTU ROUGH � �,"� -�../1��� �
NOTICE TO APPLICANT: If, afler making 1hi5 Cerli(icate Of VENTILATION SYSTEM FINAL w�
Exemption, you should become su6jec� to Ihe Workers'
. Compensafion provisions of fhe Labor Code,you mwt forth- EVAPORATIVE COOIER . VA���AT�QN '
with comply wilh such provisions or ihis permif sholl be .
[Jeeme(1 revoked. - . fURNACE: FAU�_GRAVITV
LICENSED CONTRACTORS DECLARATION FLOOR BTU �
I here6y affirm�hot I am licensed under provisions of Chapter 9 HEATER: SUSPENOED 11NIT�
�(commencing with Section 7000)of Division 3 of ihe Business ' WA«
and Proiessions Code,and m license is in loll force and effecF, - - . r
'' (' 6 5V I�S 7�' o
License Number�llc.Closs v� - � V
(�� A �
�lQ���l/�v 7`1��Dole '� ' =�.i�.�l� � .
Contmc�or� _�_
❑ • • • ~
1 om exempr under Sec. {} e •� W
Plan check fee /� I • 1 0�,5 0 �
B.&P.C.for this reason� J � .
PERMIT ISSUING FEE S (� . . � p j�Q= —
Dme: TOTAL FEE f � jO
Signafure . . G�G(�-_�'�. ,
OWNER-BUROER DECIARATION PLAN CHECK APPLICANT � . •
I hereby aifirm tho�I am ezemp�from the Controclor's license � . ,
law for Ihe following reason(Secfion 7031.5, Business and N.4ME /�C � j /� -
Professions Code): � JI.,,,
❑ I, as owner of Ihe properly, or my employees wilh ADDRESS z�� Z �'j)✓X�� �-
- wages az their sole compensalion,will do fhe work and CI7V '�.�A� TEL NO. 5' L�
the strudure is not intended o�offered for sole(Section �
7044,Business and Professions Code�. � . TU ` / -� .
OWNER _� /��
❑ I,05 owner of the property,am ezdosively[ontrpCting MAII �
� with licensed conrracrors io construd the project(Sec- qDDae55 `' � �j � U -�
tion 7044,Business and Professions Code). -
CONSTRUCiION LENDING AGENCY —`
CITY � TEL.NO. �a�
I hereby affirm ihat there is a construUion lending agency for -
the performance of�he work for whith this permit is issued CONTRACTOR � � ' " ,
(Sec.3097.Civ.C.). � . r . -. �
ADDRE55 ��
Lender's Nome p
CITY 2�� TEL N�J ./)�
Lender's Addres� �� �
I cenif that I have reod this a lim7ion and s7ote that the STATE UC.
y pp LICENSE NO. � /1� C�A55 ��
obove informa�ion is correct.I agree lo comply wilh all Coonty ,
ordinances and Sfate laws reloting to building conshudion, . _ � _ _. , , _ . _ , ,, __ ,. _
ond hereby authorize representa�ives oi this Counly.to eNer � - � � �
upon e ob e- ntioned propeny for inspetiion porposes. SEE REVERSE FOR EXPLANATORY LANGUAGE .. .� .. , .. . � _ .
a -`,�� ��—�'� ' . �
Sig t�re of Appliconr or A Dote .
. '.? . ' . . , - . � . ._ .,
_ ... .,. . . . . .
` � ' ' "' ' ' � INlfECiOR'S NOTES OWNEF.-FiUILDER DECLARATION '
� . � �I hereby afFi�m thet t om exempt from the CoMroctor's
' '� � ' ' ''� ' �- Licr.nse law for thc followin9 reasvn (Sedion 703I.5.
.... _ _v....._ ..-...... _ .. ...._... ... . ................. . ...._._..__. .. . . ...._ ._ ... ___.__. ..
o��r�ess o„d v,o���s;o��Code):Any cify or counfy which
� . � , � � �. � � . requires a permif ro ronsfrucf,alter,6nprove,demofish.
. •__.___._.. �_�_-�. .�. . �__ . . .. � �� '�� or repoir any sfrucfure, prior fo il;lssuanre, also te-
� . � � - „ qulresfhecpp(1canHorsucApermi�lolileas7gnedsfofe-
i :
� --�--��----- ---�- � �� -- �- � -� �, � � �� ' '� ' menf fhel he is licensedpursoanf to Ibe provisions of l6e
' - .. , � �, � Confracfor's�License Law(Chap�er 9(commencing wifh
��""' ""'" '""��-"' -'"'"-" '� '�-'� "' " - � - � - Secflon 700Jf of Division 3 of thc�uslness and Profes-
' , � , . � - ilons Code)or that he��is exempl therefrom and tfie bazls
' ;.� j � . � � . � � � - � � Ior ihc alfcged�cxemption. Any viala�ion of Sectlon
; ; '�, ! ; � 7031.5 by any applicoN for a permif subjec�s 1he oppli-
._ __-...._._. _ _.. ... . . ._ ... _
� , . � . . . , _ , . � � ��cant 10 a civil�penblty of not more Ihon (ive hundred
_ _ ; : dono�s(Ssoo�.:
' "'-`` ' ;(•��,:�i� __ . . . . . '� - ' : ❑1,�s owner of Ihe properly will do Ihe wo•k,and
:.__.___. __ __ . __. _ _
. , �� ;i�� � ,� , . , , . � , - the slructurc is not inicnded or offercd for sale.
��--� �-�--'� '�---- - ` � � - -� � - - � � ' .{Sec.7044,6uslnesi andProfessions Code: ihc Confrac
� • .-9: , � � � , . . !or's(Icense Law does not opply lo cn owner oI property
�-- --���� � � � � - � ,who builds or,improves fhereon, ond who does such
� � �, . . � � _ � ork himsell provided Ihal such�'rmprovemenls aro not
�, � � � � Infended or�of!cred 1or safa.l(,�howevcr.fhe building or
� �. � - ._ - . �� ,� improvemenl Is sald withln one yoor of completion,�hc
� �-- - - - - � - � owner-builderwl!lhavefhc6urdenolprovinglhathodid
' - , , • . nol build or improve!or 1hc purposo of sole.)� �
- - ❑I,as awner of ihe property,am exclusively con-
, . � . . . � . Irocting wilh licensed cvntracters to ccnsrr�cl the project
� � � -�----- � - -- --- � � (Sec.7044)Busfness and frofessions Code:Tho Conlroc-
. � � � �, � �� for's Ucense Low docs not apply fo dn owner of properly
� ' ' - ' � - . who builds or fmproves thereon,and who coNracts lor
� . . � � � �� � � - such projecfs wifh a confracfor(s)17censed pursuanf lo
• .. . . �.. . .�. _ .the Confractori Llcense C6v�J, � . �
_ � � � I am exenpt under Sec.
� B&P.C.�for this�rea�on
� ,, .._. .�.. . ._ . ._.._ _. _ .. � - � � Datc � .' ' ,. . .
t._.._.. ___.. �� � � ' . . . . . . . .. . � .
� .. _ _. . _- - � . .... � . . : Owner . .
. _ . ,. - . . . .. .
INSPECTOR'S NOTES i ' - �