HomeMy WebLinkAbout1243A J WORKERS'COMPENSATIONDECIARAT�ON APPLICATION FOR PERMIT � �
I hereby affirm fhot I have a cerfifitafe ol cansent to self
insur�,or a.ceutificate of Workers'Compensatian Insurance, MA3�� HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec.3800,Lab.C.) ,�
�n�,�J��� �E���� CE-818(REV.IOiBI) .
P❑olicy No.�C�(_J�'`"�Company . - . .
Certified copy�s hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
�Ce�tified copy is filed wi�h� e coumy building inspeo- - FOR APPLICANT TO FIIL IN BUnDiNG �/�
tion depanmem. r(,� �y�
__�^ ^t��f (PRIM OR TVPE ONIY) ADDRESS
Dote A ���'ci/[rir �. �n,.i� �-
NO. TYPE OF A7PlIANCE OR EOUIPMENT . FEE �r�f��
� CERTIFICATE OF EXE FROM WORKERS' NEAREF �
COMPENSA O INSURANCE CRO55 ST.
(Thts s�ceio�nwd not 6�mmple�rd tf fha work Inveiv�d by �+g50RPTION UNIT,B1U plSiRi�7 NO. FqOCE�Bv
}h�p�rm�t L for oa�hupdr�d dollon(SI00)er I��s.� � AIR HANDIING UNIT,CFM t�
� I certify that in fhe performonce of the work for which this
permil is issued,1 sholl not employ any person in pny manner BOILER,BTU
so as to 6ecome subjecr to rhe Workers'COM11PEfI5O110�1 LOWS. AGVROVA�S � DAiE INSPECTOR'S SiGNATURE
Date epplicaM � [ COMPRESSOR,BTU ����6a'� �p �� ROUGH Vl.���
NOTICE TO APPIICANT: If, afler making this-Certificate of VENTItATIONSYSTEM F�NA� '^�..(.&Y
Exemption, yo� ahould become aubject to the Workers' .
Campensarion provisions of the Lebor Code,you must forfh- EVAPORATIVE COO�ER- � . VALIDATION �
-with mmply with euch provistons or this permit shall be
deemed revoked. FURNACE: FAU_GRAVITY �
. LICENSED CONTRACTORS DECLARATION F�ODR 9iu
� I hereby offirm ihat I am licensed under provisions of Chopter 9 � HEA7ER: SUSPENDED UNiT� � �
.'(commencing with Section 7000)of Oivision 3 of ihe Businezs �'�'A«
and Professions Code,and my license is in full farce and effecL � � - �'
�!� L_r �O.�Tt�-�a-i�/-Z.T �� fa . G.
Lice e Numbe������ Lia Class��Q - , VO
�
a'
q � ✓� U Dofe . � O
H
� am exempt under Sec. w
Pian check fee o-
B.&P.C.for ihis reason� �'
PERMIT ISSUING FEE S �� i� z
Date:
' S�gnoture TOTAL FEE 3 � :1 2 G.3 A
OWNER-BUILDER DECIARATION PIAN CHFCK APPLICANT � �• • • • •8 .
I hereby affirm ihat I am exempt from 1he Conlrpcfor's License
Law far fhe following reason(Section 7031.5, Business and NAME , . , � • •3$,�p
Prolessians Code): �
❑ I, os owner of ihe properfy, or my employees with ADDRESS , • • •3 Q���
wages as�heirsole compensarion,will do the work and
fhe struc�ure is nol intended or offered for saie(Section Ci7Y Te�.No. 1 0.1 5—8 7 _
7044,Business and Professions Code). �
OWNER
❑ I,as owner of the property,am eztlu5ively Controcling MAIL � '
with licensed contracfors fo construtf the project(Sec- qDDRE55 �
tioo 704G,Business and Professions Code). � �
CONSTRUCTION LENDING AGENCY � prv rei.r�o. - �
I hereby afiirm that there is a construcifon lending ogency for , �
the performance of�he work for which this permit is issued �OMRACTOR�mS���T/�tJ �i
(Sec 3097,Civ.C.J. / �7 . . .. .
ADDRE55 N'��/ /N� . . . _ . ! ._. � �. . .� .. . .
Lender's Name
CITY , � tN TEL.NO.��--( � . . . . _ . .
Lender's Address
STATE IIC, CJ"q
I certif �ha�I hove read fhis oppl�caiion and state thot the ❑CENSE NO. ��d C�n55 Cd . . . . . .... _ _..
obov nformotion is mrreU.I ogree to comply with all Couny
ordi nces and SIa1e lows relating to building construction,
a hereby a thorize represenio�ives of this Counly to enter - ' -��� - . ' -� � � -
pon the ab v e�yoned pro�krry for inspecrion purposes. � . SEE REVERSE FOR EXPLANATORY LANGWAGE
�/�jLiY,���
S�gna�ure of A � Agenr Date � . � � � �� ' "� � ��
� � " � • ' ' � INSFECiOR'S NOirS OWNER-BUILDER DECLA�ATIbN
- - -- , - -�1 hereby aff�rm�ho�t om er�mpt irom thn ContraGor's
�"-� - �' � " "� License Law for the following reoson (Section 703L5.
. -.... .__._ ._.-....._............„,. _. _ '... . _,_._. . ___. _.. ..,.._ . . ... .. . .. .. ... . . . gusinossandPro(esslonsCode):l�nycilyorcaunfywhicb
� "���" `�: , ., (:"���" � � �' requires o permif lo construcl,o�ler,improvo;�demol/sb. �
� ;} ^ � -� '- � -' ��� � ' � � � or repalr ony sfrucfure,prlor ro Bs�Issuance, olso re-
,� \ �„ . � . ' �'.• qoims fbe opplicant(or such permlf lo fife o signed state�
..��..a�. � [�: - . .. . . . . . _
� - -- - - �- "--- -- � � ' � ' - - menf thot he Is Iicensed pursuant lo fhe pravisions of the
- ' � - Confra[for's Llmnse Cow�(Chopfer 9(commencing wlth
..'" '�'..,..".. , . . ... ..' ..... ..'. -. ."" � . � . SecMon 7000)al Divis/on�of rhe Buslness ond Proles�
� � � . � sions Code)o��hof he is exempl fherefrom ond Ihe basis
' . . - _ . • . . . � .. . for �he 'allegsd�e mption.-Any Jiolo�ion ol SeUlon
xe
� � . .703I.5 by ony appl�mnt for�a permi�subjech fhe appli-
... _ . __... _. _.. _ _. . _.. ___. .._.. . ., .
. , . � , . : . . -� - � � cant fo a cWil penoly of no�more then.five hundred
--�- � -- � - - -- .. .. � � dollaras(5500):
\ . � � �_„}�' � � � � . . . . I,as owner of the property will da Ihe work,and
� � � , , , . , . . .- ihe-structure is nol intended ar ofEered for sale. �
'- �-- -- ------ -�- = -�-- - - -- � � � � . (Sec.704d,Buz�nes'sond.Pro�ess�nnsCode� 7heConlroo
� , �. . . �fols Llcense Low dacs nal opply to an owner ol property
'� � � who builds or Improves fhereon, and who does svch
� . _._ � . work himseH provided Ihat such Improvemenfs ore no�
. - - � - - � IMendod or ollered(or-sule.If,however,�fie butlding or
_. . � Improvemenl Is sofd within one yvor o1 compleNon,�he
� �� � - owner-builder wlll hove ifie burden of proving tha�he d/d
� � , , � , not butld or fmprove/or 1he purpose of sale.)
' - - ❑I,as owner of 1ho pFoperty,am exclusively mn-
. � � �Iracting with licensed con!roctors to.constrvcL Ih=projeU
. � - � -� ISec.70dd}Buslnesz ond Prolessions Code:�Thc Cont�ao
. �� . - for's License Law does no�apply lo an owncr oi properfy
� � - �- - - - who bullds or Improves fhereon,and who mn}roc}s for
' � - such pro�ecis w(�h a contracfor(s)Ilcensed pursuonl lo
' ' � - --ihe Contractor's Lltense Lawj. ' � '�
- _ . . . . _._. . . ,
,. � ��. i � - � , . .. _ _ . _ . . .
� '` ` ' ` � � - � I am exempt under Sec.
. . �'. � � �'�� .. - B 8 P.C.for this reason . ..
_.. _ ... . _ . .... . .--- � � "
� ,
. Date
_ ._ . ....-� -- � � - -- . Owncr . .
INSPECTOR'S NOTES