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Home My WebLink About1327A WORKERS'COMPENSATIONDECIARATION •� �' APPLICATION FOR PERMIT � I hereby affirm that I have a certifica�e of consent to self --�]� ` insure,or a certificote of Workers'Com nso�ion InSoranCe, �bA�4C� HEATING - VENTILATING - AIR CONDITIONING �� or a certifi c S c. 800, C.) CE-818 REV.10/81) �� Policy No. �P�Y � . . . � � .Cer�ified copy is hereby furnished. �� COUNTY OF LO$ANGELES - . - BUILDING AND SAFETY� , Cert�fied mpy is filed with fhe tounly building in e FOR APPLICANT TO FILL IN BUILDIN � li de 1 (PRINT OR TYPE ONLY) ADDRE Date�PPlicanl IOCAIIiv NO. TYPE OF APPIIANCE OR EOUIPMEM FEE CERTIFICATE OF EXEMPTION F OM WORKERS' NEnREST COMPENSATION INSURANCE CRO55 Si. �.� (This s�ction n�ad nof b�complol�d I(th�work inrolv�d by ABSORPTION UNIT,BTU oistaiCr No. va ESSEp BY� tha parmit Is for ono hundr�d dollars(f100)or Ioss.) I certify that in ihe performonce of the work for which this AIR HAN�LING UNIi,CFM � permit is iss�ed,I sholl no1 employ any person in any manner ' �n so as to 6ecome subject to�he Workers'Compensation laws. BOILER,BTU APPROVAlS DAIE INSiECTOR'S S�GNATVRE _ Date app�i�o�� COMPRESSOR,BTU ROUGH � � NOTICE TO APPLIUNT: If, after making this Cerlifimle of VENTILATION SYSTEM FINAL Exemption, you shoold become subjec� ro tha Wo�keri � ,-^,� Compensation provisions of the Labor Code,you musr for�h- EVnPOaATNE COO�ER VALIDATION � wilh comply wilh s�ch provisians or Ihis permil sholl be deemed revoked. � FURNnCE: FAU Y LICENSED CONTRACTOR$DECIARATION FLOOR I hereby affirm that I am licensed under provisions of Chopier 9 SUSPeNOED UNiT_ .� '(commencing wilh Secfion 7000)of Division 3 of fhe Business HEAtER: W � ond Professions Code, my lic nse is i full force ond effe �' R L(cense Num6er .Clas , V / p_r Confrq� le 0 ❑ I am exempf under Sec. ' . � w Plan check fee i_i �2.7 A y B.BP.C.for ihis reason PERMI7 ISSUING FEE S e e 'Z— Date: t�� • •� 5gnature TOTAL FEE � o o�S�,C� OWNER-BLIILDER DECLARATION PLAN CHECK APPUCANT � � I hereby offirm thoi I om exempt from ihe ControUor's License , � ` �' °�'��r'`� Low for the following reason(Seclion 7031.5, Bosiness and NAME � L.G�—�� Professions Code): � , ❑ I, as owner of the property, or my employees wifh AD�RESS wages os their sole compensation,will do�he work and , '� the structure is not iNended or offered for sole(Section CITY TEL.NO. . 7044,Business ond Professions Code). � O W NER ❑ I,as owner of the prope�ly,am ezdusively controclinq with licensed tontractors io construct the project(Seo- �"�a�� tion 7044,Businees end Professions Code). A�oRe55 CONSTRUCTION LENDING AGENCY �r / .NO. I hereby aifirm ihal fhe�e is a construclion lending ngency for � � the performonce�of�he work ior which this permii is issued COnl7enCi0 (Sec.3097,Civ.C.). " . - . - - ._.- . . ' � ADDRE55� - � Lender's Name ' vo. Lender's Address STATE �C. I certify thot I hove reod Ihis opplico�ion ond stme that the IICENSE NO. CLASS �� above information is correct.I agrce to camply with all County , ord�nonces and State laws relating io boilding consrruction, . � , and hereby authorize representa�ives of this County fo enfer . . � - --- " . upon t abovc-mcntionc pr crty for inspccrion purposcs. SEE REVERSE FOR EXPLANATORY LANGUAGE Siqnalvr f Appli<an�-- - /�✓ . , . ' . . . . � . . .. �. . .. C� - - - , � • � ! � ' ' ' ' � IN9tECTOR'S taoTES 1 OWN[R-EUIIDER DECLF�RATION ,., , _. . ., +�,� ,, ,. - - . ..�, . �1 hereby affvm ihal I am c+zempt irom:the Contractor's .� I-=' �" - � , � ,.'Licenso Ldw for tha�follov.�ng reason (SecHon ID3L5, , -� '� �--- ', �� ' .'�- �- - '-' -�� - - � � -- '�� ' -� � � 8usincss'cndFro/essionsCode):n�ycuyorco�n��L.htch . ��\ � , � � ' �equfres a permii�o mns�ruct,oller,�mprove,demolish, ' ' - " � "" " - � - � ' � � ��or repalr ony�sirucfure, prlor�fo.i�s/ssuonce, alzo re- � � � � � ' � , �,qutre's.1he applican�for sucb permif fo file o signed s�ale- - � � �- � � � ��- -� � - , ' ' � � ' � mont tho}he ls licensed pursuonf fo fhe provisfbns af fbe � � � Confracfor's Lkrnse Law(Chopter 9(commencinr�wl}h � � " �� --� � � � �� "� ' " � � Secllon 7000f of Dlvislon 3 0/fhe Busfness and profes- • � iions Code)or fhof bels exempt iherefrom and fhe basis � � ' . � . _ . For the alleged exempiion. Any violalion ol Sedion � ' � � , .� , 7031.5 by any opplicont lor,a permu subjens Ihe opph- � � � canf tv a civi!per.ol�y of not more fhan (ive hundred ,. ... � . . ... „t' - �^... . ` �: \ '1 dollvrs(5500): ' � ' � ❑I,as owncr of ihe prope.rty will do Ihe work,and � � � � , , � - - �he struuure is no�intended or offcred for sal�.- -. �� - - - -- � - - � -- - � � , (Sec.7044,Qusiness andProfesslons Code: �The Confroc- � � . , � ror's Cicense Lcw does not epply}o en owner ol.property . �� who huifds or improves Ihcreon, and who does such � �i _ � work hlmself provided�hot such improvemen�s are not ' � - - ' 1 infended or o!(ered lor eolc.1(;however,the bvilding or � . _ . . . . . �mprovement Is sold wilhln onc year of complefion,the , '� � - � � owner�builder w�fr'havo fhc borden ol provtng tbat he did , , _ _ _ - . not build ar mprove!or Ihc purpose ol sol.^.) . ,�'� ��-� ' '.�I,as owner of ih�propCrtY,am exdosively mm � , , -' �irocting with licensed conlraclers ro consduct the project � - - `.,.(Sec'7054)9usiness ond Professions4 der-ihe Contrao- � � � , . for"s L7cense Low docs rtol opply}o an dwner o1 properfy � ' wfio bullds or lmproves fFcrcon,and who eonfracts for . . � . � - �� such projeds with a tonfrccfor(s)liccnscd pursuani fo , , - tFc Controdor's License Low). ' � ' I am exempr under Sec. B&P.C.for fhis reason � . \. � � .�_ � , . , , ��..� ; Data , ., . , � . _ - . \ . �� Owner � ' — ' ' -i , . !_. INSPECTOR'S NOTES �.�` _ ' - . }c.._ - - - �' ti, , � . . .... . . . �l 5 . - �`.� .. _. . _ . . . .. . \ _' ' __ � .\�\` �� . ._ �`