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HomeMy WebLinkAbout0830A WORKERS'COMPENSATIONDECLARATION APPL�CATION FOR PERMII � I hereby offirm thm I have a certifica�e of consent to self . insure,or a certificate of Workeri Compensmion Insurance, '76A3�� HEATING - VENTILATING - AIR CONDITIONING or o certified copy thereof(Sec.3800,1ah.C.) _ CE•818(REV.IOiBi) - P❑olicy No. Campany COUNTY OP LOS ANGELES BUILDING ANO SAFETY Certified copy is here6y furnished. � Certified copy Is filed wiih the county buiiding inspeo- FOR APPLICANT TO FILL 1N BURDING /^�n /�n �ipn departmeM. - �pRINT OR TYPE ONLY) ADDRE55 tijl � �Cy���' Date Applicant IOCAIIiY A.^ G. . NO. 7YPE OF APPLIANCE OR EOUIPMENT.. FEE �� � CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST � ,{�y� � . COMPENSATION WSURANCE ' CROSSST. i7 f�- �T{li{SK1I011 IINfI not b�tomplot�d tl tha work In�olvrd by Ag�RPTION UNIT,BTII DiSTRICT NO. PROCESSED BY th�permit Ia(or ona hundnd dollors(Z100)or Irss,) qIR HANDLING UNIT,CFM � L+�„{/ I certify ihal in the performance of Ihe work for which ihis ��� -�_ -� permit is issued,I shall not employ any person in ony monner � so asrtyo become svbject to Ihe Work s'Compensation Laws. bOILER,BTU avaaovais onie INSPEQOR'S SiGNATURE Date •~"� "r pplicent,� Y+ v� COMPRESSQR,BTU ROUGH NOTICE TO APPLICANT: If, after making�his Certiiicote of ' VEN71lAT10N SYSTEM FINAL � ����, Exempiion, you sho�ld become subject ro the Workers' Compensation pro��sions of 1hc�Labor Code,you mVs1 forih- . EVANRATIVE COOLER . vA���AT��N' with comply with such provlsions or this pe�mii shall be � deemed tevoked.- ' FURNACE: FAU_GRAVITY . LICENSE�CONTRACTORS DECLARATION fIOOR BTU � �� I hereby affirm Ihat 1 am litensed under provisions of Chopter 9 SUSPENDED UNIT_ '(commencing wi7h Seclion 70D0)of Division 3 of the B�siness HEA7ER: WA�� ' and Professions Code,ond my license is in full force and eifett. �J 1� - 1'7s a ! License Number c Class� �� � , � (�� /j�, L�,t /� rr :C8'JOl1 0 CoMractor�p![I�_�QI'^ p1�i1e�= ❑ �; o • . a •Sj � I am exempt under Sec. w Plan check fee N 8.8P.C.for ihis reoson� � • • � C�Jr Date: PERMIT ISSUING FFE S ��U.S� o o � Signafure TOTAL FEE ,�,�5 � � ��S T OWNER-BUILDER DECIARATION PIAN CHECK APPlIfj1NT � G �'�7_r`C' I hereby affirm that I am ezempt from ihe Conlraclor's License , ► Law for the following reasan�Section 703L5.Business and NAME - . Professions Code�: � � - ❑ I, as awner of ihe property, or my employees with ADDRESS wages as their sole compensation,will do the work and the strutture is not intended or offered for sale�Section �IiY � TEL.NO. 7044,Business and Professions Code). � OWNER � �`., ❑ I,os owner of ihe property,am exclusively coniracting wifh licensed mNractors to construct the projecr(Seo- �'�� � O � lion 7044,8usiness and Professions Code). � kDL1RE55 CONSiRUCTION LENDWG AGENCY Cltt D TEL.NO. r .-(Fj�' C I herehy affirm that�here is a construction lending ogency for r � '� � � '. fhe performance of the work for which thls permit is iswed �OMRACTOR Yb�J Q 1�-�-C �- (Sec.3097,Civ.C.). . . . }r .. .. ., ._ . _._... . . ' - ADDRE55.�O I �.. JYI,Y�/'L .. . . . . ., _. ' .. .._ .. . . Lender i Name � Lender's Address -�� CiTY �- �� � ��; EL.N�3 z�� �ti _ .. . . . . . I tertif thal I hpve read this a licotion ond state 7ha1 the StATE UC. �f y pp LICENSENOY�� 7vz C1A55 7J I .. ._ .. _ _. ..-. ahove information is cortect.I ogree to comply wilh all County . ordinances and State laws relating to building consrruction, � and hereby authorize repre atives af Ihis Counly to enter , " � �- � - � - - "� '-� ' ' upon the above-meniione pr per�y for inspeciion purposes.`f SEE REVERSE FOR EXPLANATORY IANGUAGE . � CC.tta [� 2t.w�-T� 7 �-.Z�—[J Uf . . . .. . _ . Signo�re of Applicant or Agent �a�e ' � - � -� - � ' • ' ' - -��- - � - ` ` ' � - • ItdSPetTOe'S NOTes ' OWNER-BUILDER Dc'CLARATION �� -.�-, -. .� - � . - .. . .-,, . .,..-. � -�----I hereby affirm that I am exempt from�ho Con�ractor's '� � � � License Law forrhe following reason (Secfion 70JL5, _._.� __ . .... . . . _ � � �� t . _ � . . .-.".... _".- .. . -. . -: --.:..- .". . . .._'_. .. . Buslness and Pro�essions Code)r Any cfty or rounf y wh7ch !!� , , �,i:' �L.,._ � '�-�i _1,',�� � . ' requires�apermi�to construc�.afrer,Improve,demollsh, - `, ��,� �.� r , � - � ' � � � ' �' o��epai�vny sf�ucfurc, prior�o�lfs 7ssucnrn, ofso rc� )_.__ _.._.. � +,___ _/ . �_�i . ..��,.��.�, . ...� . . .. . , . • _.. _ _qulres fhe applicanf lor such permll la file o signed sfale- . ., i ; � , ,_ � � - mcnt ihal he fs licensedpursuant lo the provlsions of tho ,�•,_ � -r',���� .,:`�.��) , � Coniroctor's License Law(Chapfer 9(wmmencing wffh . . . �� � � '-' .Src�ion 7000J oLD/Ws/on 3 0l Ihe Business ond Proles- . ' � � � � � � �s�ons Code)or}ha�he is e:empf therelrom and the bas/s � , . , ... . . � � � � " -� � � � ' �or fhe alleged exemp�ion.� Any vlola7lon�o!Seclion �� r � , �J031.5.6y any applicant lor.a permll sobjttcts�he oppli� , _ _- ----- . ... . . _ , . .� � . � . �� - . � , � -- -� - � � ' � ,.mnt fo a tiv0�penoffy of not more fhan flvo hundred •' . .. ... -� -- - - �. . -. .... dollars(5500).: ' � �I__ . . � �- ---�-- � ;�,`�,{ �;�t7 I,�as ow�er�of,the property�ifl do fhe�work,cnd ' ' - �. � . . � �,-the struUore�is not inlended or.offered for sale. . . � - � � --- - - � - - �� � --- -- � � � � (Sec.7044,Business and Professions Code: 7heConlrao . � , . ., , �•tor's Llcense Law does nof apply 10 an owner of praperfy � � �'� __���. ._ �'�. who�bWlds or fmproves Ihereon, ond who does such _ _. ... . ._ _ � , . . . • work hlmsef(provlded Ihaf suc6(mprovemenls ore not - � � ' � lnlmded or�oflered(or sofe.ll;bowever,fhe building or . � . ... . _ . � . . . -improvemenl Is sold wffhfn one year oI compfe}lon;Ihe . - � -� - � - � owner-buf(dcrwtll havc ihc 6urden ol proving lhaf he did � .�1 ', ', � ', � � f no�bufltl or lmprove/or ihe purpose o!sole.J , ��. • � . :.. .-�- � \ ` �'. '�- ' .. 1 ..' �...t.�I,as ownerofithc�property,am exclusively mn- . � i � � �� �"--" ��act;ng with licensed conlrod0�c ib�consiruct Ihe project � �� - - - - - '"��'.(SecJ7A44)Qu3lnc;s.and,Prolesslonr.Cbde:TfieContrac- � � �� ! --� to?'s Llcense Law does nof�opply)o'on owner o1 properly � " � -� �- _ who bvilds or Jmproves fhereon,and who contracf4 Ior � � ' � � " � � '''"- socF proJects w1�b o con�racfor(sJ ficensed pursuan�to _ . _._... . _ _. _ ... . _. . � � - - ��tfie Controctar's Licensc LawJ.� � � � ' � � � � � I am ezempt onder Sec. � . . . .- �, � . . . . .. � B&P.C.for this reason �� ,. . . - -- . __ _..__.. _._ _ _._ . -_ � . . . , ,, ,� . �- 1. . � � � Date .. . . ... . ' � t 1 � �-`� 't �1; � _� - !1•- � . . - . . .... . . , , r I 1.:il,':I... !. ,. , . .. . � _ _ .. , . ���+ t�\ . . . .� ' . Owner - ., . , . . � , _ � .. . . . . . :, .. ... � . . , . . �- .. ,, ��: ' _.�,� . I..i+ iJi ;.�. , . . � .__..._�-�'. " ' -„ ..� '-� � ' �; ... . , ' ..,' . '. . . . - INSPECTOR'S NOTES - - � � �"" ' � � -- - -��� � , , � , . . ., , . �.,- . , �. :� . _:.-_. ..- .' . ..-. . . _� . . -�' ._ -. -. .____ ._.. __ . . . .. , . . . . . , . ....._ _ � . _ . . � - t �, ..` , . . _ _._ .__.._ _. _._ ._. _ . . � � - •,'{�; _ r _ . _ .., �. . .>_ - . . _ _ .. -. . . ._ , . � �