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HomeMy WebLinkAbout1244A WORKERS'COMPENSATIONDECLARATION � . APPLICATION �FOR PERMIT � I he�e%�y aftirm tha�I have o certificate of consem�o se�f insure,or o tertifico�e of Workers'Compensation Insuronce, 76��� HEATING - VENTILATING - AIR CONDITIONING or a cer�ified copy thereof{Sec.3800,Lab.G.) �7 CE-818(REV.10i81) - - - - � P�olicy No��Compan;,r��{,/ � Certified copy�s hereby'f�rnished. T CdUNTY OF LOS ANGElES . BUILDING AND SAFETY � Ce�iified copy�s filed wuh rhe un ilding i�speo FOR APPLICANT TO FILL IN BU4DIN tion deportmenl. (7RINT OR TVPE ONtY) P.DDRES L �j� Doie Applicont u. � G',�+ � NO. TYPE OF APPLIANCE OR E�U�PMEM FEE CERTIFICATE OF EXEMPTI WORKERS' . NEAREST � COMPENSATION I R NCE � � - CRO55 ST. � � (Thfa s�ction na�d nof b�tomplN�d if Ih�work involvad by ABSORPTION UNIT,BTU o�srcic�No. vaocessco av tha p�rmi�I�lor ona handnd dollars(SI00)or Ioss.) 'ti—� ' I tertify ihot in ihe performonce of the work for whith Ihis AIR HANDLING UNIT,CFM � permil is issued,I shall not employ any persbn in any mvnner gOIIER,BTU `^\ so as to became subject�o the Workers'CORI�J2f15011011 LOWS. AFPROVAL$ � OAiE INSVECTOR'S SIGNATURE COMPRESSOR,BTU �G•� O p� ROUGH • Oo1e Applicant . NOTICE TO APPLIG4NT: If, ofter making this Certifimte of VENTILATION SYSTEM FINAL :'�,{`� � � Exempiion, yoo shooid become subjecr io the Workers'._ Compensation pro�isions of�he Lobor Code,you must fonh- evnaoannve eooiea VALIDATION with comply wilh such provisions or this permit sholl be � deemed�evoked. - - FURNACE: FAU_GRAVITY� � LICENSED CONTRACTORS DECLARATION FIOOR Bitl I hereby affirm thof I am licensed under provisions of Chopler 9 HEAiER: - SUSPENDED UNIT__ - ' , '�commencing with Section 7000)of Division 3 of the Business WA« . and Professions Code,and my license is in full force and effect � � - � � - �"' a o�r�,_.r��b� /� :� a /J O Ucense Nu er V Lic Closs G� � � ► � 11 Contract / •/5� - � . � O ❑ I am e e pt under Sec. � w Plan check fee N �B.87. For this reason' PERMIT ISSUING FEE S /U � � � Oafe: :.� 2�'..L4 F� Signatore TOTAL FEE '�Q �XJ ' OWNER-BUILDER DECLARATION PiAN CHECK A7alIGnNT � ,�a • � o . � I hereby affirm thal I am ezempt from the Contrac�or i license , � � . Law for the following reason(Seaion 7031.5,Business and NAME � ' '3�r��� Professions Code): � - � R F ❑ I, as owner of Ihe properly, or my employees with ADDRE55 � . °`3������ � woges as Iheir sole compensotion.will do ihe work ond I G.1 5—�7 . the sfruUore is no�intended or offered for sale(Section CITY TEI.NO. 704d,Business ond Profess�ons Code). � � - OWNER ❑ �I,os owner of Ihe properly,om ezdusively conlractinq with licensed contractors to construd the projetl(Sec- � P'�°��� - ' �� �� � tion 7044,Business and Professions Code). ADDRESS CONSTRUQION IENDING AGENCY , arv � TEi.No. � � � I hereby affirm thm lhere is a constronion lending agency for , the performance of Ihe work for which�his permit is issued �Q - (Sec.3097.Civ.C.). . � .. . . . . . . - - . ' � ADDRE55 �� . . �- .. � . . . . lender's Name � TEI.N Lender's Address � � � I certif thm I have read Ihis a licotion ond stote thot the S7ATE uC. �r y pp IICENSE NO. -CLA55 - -- - - -. .. abave informatian is correct.I agree to comply with oll County � � or 'nances ond St laws reloting to b�ilding conslrut�ion, � hereby aut r presentatives of this County to enter � � � on the o 1 j ned propeyty for inspecron purposes. -. SEE REVERSE FOR EXPLANATORY LANGUAGE . . . .' . ' f��� • Signatvre of A �II nt r Agent Daie � �� - � � ' ' ' '��� � - � • � - ` IN!tfECTOR'S NOTES OWNER-6UILDER DEGLARATION _. .., �. - . � ; �������h�,areby-a(iii�thm I om exemp fra�n th�Contrac�or's " ''`'� ' - � '' � ' Ucenso lm.v for fhe.following�reexon (SecHon 7031.5, .._._......._._ .... _.... .._..-._. . . .__..._ _...__..._.. . . .. __.. ._�.._.._ . ... .... _ _ ... � . � BusinessandQro�essionsCodeJ:Anycilyorcounfywhich �""� � `����`. .••j , ' �reqolrei•.opeim;�foconsirucl,olleqfmprove,demolish, ��- � -� --- -- - �- �- �' � - � � � or repql a'riX sV�cturc, prlo�fo Ifs Issvoncc. also rc- i 5 p��:..� �.i i: .3.�:��. � li�`. .i. ,1 � i . . . . . . � . ��qulres IFie�pf!lcap;/or Such permlt fo Ille a slgnedstafe- _._�. � -�-- � --- ��' -�- " - �� - - - ' � ' menf lhol ha Js Iicenzed pursuon�lo�fie provb�ons of ihe � ,� Confratfor's�licensellow(C6op�er,9(commenting wifh `., .. "". . -. ... . ..,..' . ...- .. " '". ` ...' : . - .. . - SecMon 7000)ol Divis�on 3 0l thc�Business � . .. . or.d Proles- • ._ sions�Code)o��hat he Is exempt Ihcre%om ond the basls � � ' ' �-. _ . . _ . " - " for fhe olleged ezempiion�. Any violdlion-o/Seclion � -�� � _�� , 703L5 by ony,applicanf for o permir subjecfs Ihc appli� .__... . ._. ... . . ._ . _ __ ._ _ . . . � - . � - � ' , ' .� � � - . tant ta a cWd pen�lty of nof more fhon fWe hundred _... . . ..__ .. ._.. , ,�. dolfors(5500): � .. . ' " . - � ' � ' ❑I,as owner of�he propery will do thc work,ond �. _ .__..._.'___... ._. . _ '=. ", , � � - � �, � , . the st�ucture is noi iNcnded ar oficred for saie:-. .--. . � .- - � - � - - -- -- - - ' (Sec.>044,BuslneseandPrpfesslpnsCode: iheConlroc- � , �' , � . - /or's lfmnse Law does nof opply fo on awner ol property . . - --�� - ,,_ �. _ _., . ., .� � who 6u(fds or Improves �hereon, and who does such ; . . � . .- , work himsel/provided thal sucb Improvemenfs are nof � - ' ' � infended or ollered lor sole.tl,however,thc 6ullding or � - -_. .. . - � Improvemenl Is sold wi�hin one yoar o(.complefian,1he , , _ � � - -- - � � ' ownerv6ulfdcr wlll hove Ihe burdnn of prov(ng ihoi he did � \ __ not 6u11d or improve lor fhe purpose ol soleJ . � . . . �� • .. � � ' . " ��':'.;_0 I,os owner o(fhc G�{'p���Y;��m ezdusively con- . � ��iracting wilh license�,con!ra[fc�s�o�constr�cr ihe project � �� - - t'"•��,1$ ��'A-44 Busfnoss andProfeS.;lons ode,7he Confrac- " �:.. ).. . . .� l. _ ' � . tor"s Licbnso 2aw do0i hot appfy(o th owheC of property � �� � �� � who 6uifds or lmproves}hcreon,arid.who conYrads lor � - �� soch projecls with a confracfor(sJ lic'onsed pursucnl�o - ._ . . .._.. .. .- . ... . . .ihc Controcfor's Clcensc Law).� '. - . ' � � � I am exempl under Sec. � � . � � � B&P.C.for this reoson � � � __.. ...._.._. . _ ___ .. .. . _, � - _ ; Dafe � .. _�. . _ ._ _ .. . - �- - - - :.. . Owner , .. . . . , , . � . . . � . � . . - � --- _ ._.�.� . __ .._._ . .. _ _. . . . .. . . , ., . . � �' . r . _.�:'�� 1._<-:�..�,�.i,a..,,,; C . ,:��.. INSPECTOR'S NOTES - � � ---- -� �� - - . _. . ._ n. .._ .. ,�� • . �. -. _ . . _ ._ . . . . ._ .._ . , . ' `.�., � ,�'��. - _. .. .. . . . _._._- -- "n:.�. . ,. .... . . t\� ..a•_ . _ _ . . . .. _ _. ... . . . ' .. . ' - . � . . . _ .. . � � • . . . `��1;��'� 'e.' `�.� [ ' �l ',,ti.�� ti t � 1.1 � 1��,y 1��'. _ � ._ ,,�; \