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HomeMy WebLinkAbout1235A WORKER;'tOMPENSATION DECLARATION ' _ ' I here6y oFfKm �har I have a certificate of�o�se���o se�f � .APPUCATION F4R PERMIT fnture,�k'o cerlPficote of Workeri Compensa��o�i�,,,�a„�e, ,bn�aac " � HEATING - VENTILATING - AIR CONDITIONING � ���,� �a���,ified co there�f..(,SeF,9a00,lob.t�"�e . . . cQ l.�f� lSX �� /!�_�•aie�Rev.io�ai) Polic NaJ ` I 1 R c6rr5¢on� � Certified copy�5 hereby furnished. , COUNTY OF LOS ANGELES BUIIDfNG AND SAFETY Cerlified copy ia filed wilh�he counly nd�nq;nspeo � FOR APPUCANT TO FlLL IN fl�IID!NG tion department . (PRINT OR TYPE ONLY) ADDRESS � 'ti\ Date ' plicant � LOCALITY � �Q CERT / �NO. TYPE OF ACPLIANCE OR E�UIPMEM FEE 1� 1� TE OF EXEMPTION FROM WO ' NEaRESi 1 � GOMPENSATION INSURANCE Crt055 ST. (This a�c}ton nwd not ho tomplated if ih�work fnvolrod by � ABSORPTION UNIT,BTU DISiRICi NO. PRp�[SSED BY 1M pormil U for one hundr�d dollan(f100)or lo�c.) �\ I cerfif ihof in ihe AIR HANDLING UNIT,CFM �� _�,\� y performance of ihe work fo�which this f1�� permi�is issued,I sholl nol employ any person in ony manner `7�X so as fo 6ecome subjed fo the Wo ompensotion Laws. BOILER,BTU � � nvvaovais onre INSDfCTOR'SSIGNAiURE Dot � plicont COM72E$$OR,BTU ROUGH � NOTICE TO LICANT: If, affer making this �i[ate of vEMIIAtION SYSTEM fiNAt Ezemptlo , you should become subject ro the�Workeri '. � Compen5ation provisions of Ihe Lpbor Code,you must forfh- EVAPORATIVE COOIER VALIDATION with comply with sucfi provizions or this permlt aholl 6e deemed revoked. � FURNACE: FAU_GRAVI7V � UCENSED CONTRACTORS DECLARATION cIOOR e7U � I hereby offirm Ihal I am licensed under provisfons of Chopfer 9 HEATER: SUSPENDE� UNIT_. - �. "(tommenting wilh Section 7000)of Divieion 3 of the Bosiness WA�� /Snd Professions Code,ond my license is in(ull force and effect . j. 1 _ a License Nomber Llc.C � . , � V � CoMratl '^�'" � . 0 \❑ I om exemp�u er Sec. , W Plan check fee n, B.&P.C.iqr this reason � \ PERMIT ISSUING FEE S IU ? aie: Sgnature TOTAL FEE � O NER-6WlDE RATION �IANCHECKAGPLICANT . !hereby affirm that I am exemp�(rom ihe Contractor's license ► law for the following reason{Section 7031.5, Business and NAME Professions Code): � ❑ I, as owner of�he prope�ly, or my employees with ADORESS wages as Ihe�r sole compensa!ion,will do Ihe work and CITY - TEL.NO. the strocrore is not imended or ofiered for sale(Sec�ion '�'} 2 S Fl � 7044,Business and Professions Code). � J. ❑ I,as owner of the y, OWNER . properl om exdusively coNro[ting ^�` � '� ��� � � ��+, with licensed mntraclors to consrruct the project(Sec- qDORE55 � tion 7044,Bvsiness and Proiessions Code). � d � • •3 O.J O " CONSTRUCTION LENDING AGENCY �iTy TEi h�g �Z 1 here6y afii�m thoi Ihere is o construction lending agency for � , � ��G J�` Ihe performonce of fhe work for which Ihis permit is issued CONTRA�70R �,�,., ,� � � ($ec.3097,Civ.C.). � . ` . . . � . �8.�n—�`O� , � ADDRESS �T S ., ' � Lender's Name - ��- - � � . �I7Y O T l.NO.�� il(�`� . lender's Address C . . .. . . .. - - . I cerfif thot I hove read this a licotion ond state thot 1he STATE LiC. Y PP UCENSE NO. � G � �QA55 above Informa�ion is correct.I agree lo ply wifh oll Couniy � ��- --� � -- -- - . ordinances an �e lows relating o b Jding construction, . and hereb ihori represenf ' es ihis County fo enter � � - � -�- � / o . enuoned pro r or inspec�ion purposes. SEE REVERSE FOR EXPLANATORY LANGUACE Sign rvre o Applican qr Agen� Da�e - ' - � � � . � • • ' ' ' ' • ''It�sPcCTOR'SNOTES OWNER-BUILDERpECIARATlO'iQ• '� � . . . -�- � -- I hnieby affi�m lha�I om exempt from lhc Contractor'a � � '" " � " ' � ' Lkense Law for �he following reason (Secfion 7031.5, ..,_._ ___...._..__.....". _ ...__.. . . "'"'" " "' '� " ' "� -'""" "� �" Busincsz an Pro/essions Co c:An II . .. ... '" yc yorcounlyw ic - � � . � - ' � � � . � requires'o permif�o construU,oller,improve,demolish. �-- ��" ' " - '" ' -- ' ' ' - - � � '�— � or repoir ony,.slructuro, prio�lo iis Issuqnce. also re- • . � � � � . .. - � quires}fie appficant lor such permU�olilo o signed stote- �..._ _. _._ . . . .__. .. . �. ''... �- _ . �: . � � monf}hal he�s Iitented pursLent fo tbe provlsfons ol fhe � . ' , Confractor"s License!ow(Cl�apler 9(commencfnq wif{r� :.. ..... ... ...." . .. -... . .... " ..'... . . �. : '.��'' �' '•:�:�� , . . . Secfion 7000J o1 Division 3 01 Ihe Eusiness and Pro/es� � � , sions Code)or tha/he is exemp�therefrom�and ihe basls � , � � , ; , � � . � � � . lor ffie aqeged exempfion. Any violalion o� $ecNon � .�, : �; . � . � � � , . . 7031.5 6y ony applicant for a permit sobjecfs fhe appli- _._._..�.. .... . .. _ .._. .. � .. . . . . - . � � � � � � � � �canf to a civil penal}y o1 nof more fhan five hundred � .. . � .. . .,.:. . .. � doqars(5500).:.' . _ . . _._.�. � . .. . . . � � . . . . � � - �1 s owner of.the properry will.dL t6e work;and �I � . . . _ ���he struc�ure is nor imended or ofFerad for sole... � �--� � � �� ��� ' --- �� � �- - � � � (Sec.70d4,Business ondPro/essions Codr. 7heConfrao- � � . , . , . . .�ror's Llcense!aw does not opply to on owner of property � : � . � � � . ' �' who.bulfds or improvns f6ereon,.ond who does such . - _ � . - . wo�k himsel!providod�hcf such improvemen�s ore no/ ',.. _.:_:, .. . . ----� � � infended or oHered!or salc.If,howovcr,-�he building or .- . -- _ . improvemem Is sold within vne year o1 comple7ton,tho '� : ----�- -- -- - - � owner-6ullder will have}he hurden of proving tbot he did . � . not balld or improvo/or fhe purpose ol�sole.J �� , - -- - � ` ❑I,.as own�r qf tbe,prop�ny,am exclusWely mn- . . , � -� ��iiading��vith licen_?�d'tontraclors to conslruct Ihe proj=ct (Sec.70dk)6Vsiness and ProFessiont Code:Tho Controc- � ' �. �' for's L'leense Law�does�no!app(y to an owner o1 properiy ' �- - � � � --- � - - _who butlds or improves Ihcrcon,and who controcts for ' - - ' � � suc6 projeds wifh a tontrador(s)ficensed pursuonf ro � � .. � �. .-.. - -. .. - - ...- � - -, _ .•.1hc Conhacfor's Llcensc Law).� . . . � I am ezempl vnder Sec." � �}— B&�P.C.for this reason : : ..,, ; .,�.. . . . .. . , j--- �- -' . . . . . .. . f .. . � , . � . ' � . . ., _ . _.__.. .." __'. ... ............ .. - . ,. . , ` . ' '- .. DOIC � � ' • � �'•,.:-.'.,7t -`:1,.,., -.,; . :.. �:, i�-.-• . - . 0 ' . . . . . . .. � . , _ - _. . . ._ , _. . .__ . . _.. wner t - . � . � . - 1" " _ _ i.�• _ � INSPECTOR'S NOTES � � � � �� ' � - � � . . . , . .. . -- - __. . ._ .. . . . . . , _ � ._.. -.. . -..'-- . . . . . �. � ,. ..--- -.. ___ .. _ _. � - -- . .. _ _ _ .� -.�.- . . !