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Home My WebLink About1326A i ' WORKERS'COMPENSATION DECLARATIpN �,G�� APPLICATION FOR PERMIT .� I hereby affkm that I have a certifimte of consenl to self , insure,or a certificate of Workers'Co pensation In vronce, �6A364C HEATING - VENTILATING - AIR CONDITIONING 3 or o cerlifie ec.38 b.C.) J � CE-818(REV.10/81) - � Policy No. ny - - � Cerfified copy is hereby fumished � �J� � COUNTY Of LOS ANGELES BUILDING AND SAFETY Certified copy Is filed wi�h the county build�ng ins o FOR APPLICANT TO FILL IN BUIIDING ti departme , (PRINT OR TYPE ONLY) ADDRESS � � Da�e� � plicaM LOULITY NO.' TYPE OF APPLIANCE OR EOUIPMENT. FfE CERTIFICATE OF EXEMPTION FR M WORKERS' NEa.REST �COMPENSATION INSURANCE �ROSS Si. (ThL�xfton n.ad not b�tomplef�d if the work Involvad by pB50RPTION UNIT,BTU Di51¢iCl NO. VROCE D BY tha parmH f�for ano hundrod dollars(5100)or lasf.) � � I certify Iha1 in the periormance of ihe work 4or which Ihis P.IR HANDLING UNIT,CFM � � permit is issued,I shall no�employ any person in any manner gOaEa,Biu � so as to become subjetfdo the Workers'Campensation LOWS. pGPROVAlS . DAiE INSFECTOR'S SIGNATURE Date opplicant � COMPRESSOR,BTU .OUGH . ._.s�� G'�� NOTICE TO APPLICANT: If, afler making ihis Certiiicate o4 4ENTILATION SYSTEM FINAL L/ Exemption, you should become su6jeci to �he Workers' ,/'� - Compensotion provisions of Ihe Lp6or Code,you musl forth- FVAPORATNE COOLER � VALIDATION � with comply with such provisions or this permit shall.be deemed revoked. fueNnCE: FAu rv LICENSED CONTRACTORS DECLARATION FIOOR iU � I hereby affirm thot I am licensed under provisions of Chapter 9 Sl1SPENDED UNIT_ HEATER: W � '(commencing with SeUion 7000)oF Divisio 3 of the Business and Professions Cod , d m icense's' II force and effect. - >' //•�,��--.-,(�,�.p( a . License Num6er .CI zsS_eL,l_L.,1_ � � V Contra6{p�/.��/�� ❑ I am exempl under Sec. . . ' • iy �� .'�.C.�;FI V Plan check fee a ��• • • • O�, N B.BP.C.for t is reasan PERMI7 ISSUING FEE$ ? Date: I • ' 4 P.0� 5gnature 70TAL FEE OWNER-6UILDER DECLARATION PLAN CHECK APPLICANT . ' � " `-��%O G� I hereby affirm that 1 am exempl from the Contractor's License , , - Law for Ihe following reason(Sec��on 7031.5,Business and NAME � . � � r ��'�-'� Professions Code): ❑ I, os owner of the properfy, or my employees wi�h ADDRE55 � wages os rheir sole compensa�ion,will do the work and ' �� t8e srructure is not intended or offered ior sole(SeUion ��t� iEL NO. . 7044,Business ond Professions Code). OWNER L� � . ❑ 1,os owner oi Ihe property,om e.clusively tomrading MA1L with licensed contractors lo conslrucl ihe p�ojeU(Sec- ADDRE55 tion 7044,8usiness and Professians Code). � . - CONSTRUCTION LENDING AGENCY NQ. I he�eby offirm ihal there is a construction lending agency for . the performance of Ihe work for which this permit is issued� CONTRACTO � (Sec 3097.Civ.C.). � .. . . - � ADDRE55� � - � . . . _ Lender's Name � CI � Lender's Address A E IIC. I certify that I have read this applimtlon ond state ihat ihe uceNSe No. Qn55� -. . . .._ . _ .._ obove informotion is mrrect 1 ogree fo camply wiih all Counfy , , � . ordinances and Stole laws rela�ing�o building construction, , ' ond he e6y authorize rep esentalives of this Counly m enter . . � - ' - � r r upon ih bo e-m�j�?�{{'''t' ne pr rty for inspeciion purposes. SEE REVERSE FOR EXPLANATORY lAN ��aJd�/L�/�� GIIAGE . _... . .. Signature Applicont or Aqen� Dote . ... .. .. . .. . , _ , .. __ , _.. _ , }- , . . . INsrECTOP.'S NOTes OWNER-EUILDER DECIARATION ' t � • ....,- .. „ ;,,. .,_ , . . ... ... _ � . ' I`�ere6y affirm IFo1 I��om exempi from�the Caniractor's � " -� " ' � � � � '- ,, ,�,� Licen'se�Low for ihe following revson (Secfion 703L5, ,•� . ._ .'` "" . ...,. �_' ,___ . _ . .__ _ ._ - . .- - . Susl e.e and Frof�ss'onz Codef l�ny aty or counlQ whicF '��, � 1' � 1,� _ , , � � � . � req lres o pe1 mr1 fo consfrud,aller Improvc,demolish. � � �" ' � � :' � -� - ; ;��. •, ' � � '� � • or repair any.strudure, pNor.�o 7�s issucncc. o�so�rr '.., �- �' ',��,' , -, , �� S , . •, ��,'•. .,�� quirc�Iheappficontlorsucb'permi�toiileosigneds�afe- �� - �� -� - ' � � � -�� ' - � ' � � ment Ifiaf he!s licenzed pursvanl fo fhe proNslons o/l60 ' � � . Con}roclor'S 1(cense!'aw(Chapfer 9(commencfng wHh �� " �"� � -� �� ' �-"�� - �� _ ' Sec�lon 7000)oi Division 3 0l fhe 6vsinezs ond Prolcr , , � s�ons CodeJ or lhat hc h exrmpi�6rreGom and�he liasis , � ' ' � � � for fhe ol/eged exemplion. Any�violation o!Sedion _ . ._. __ . . _ .__.. . _ .. � � 7031.5 by any opplimnt/or a permil su6jens thc appH- . - � .. � ' cant fo a civl!penolty o1 not more;fhan five hu�d��d � . ' . _.. _ . _.. . . . .., '.., . , 1 dolla�s(5500).: � - . ., . . ..` L � � ��` - ��- -� '�-�� ❑I,os ovmer of thn property will do the work,and � - � ihe struUure is not intended cr of£med for sale: I ��- ��- �- � - - � - � � {Sec 7044,Qusiness ond Praiesslons Code: Tfie Confrac - .. � ' ' ; • , for's Llcente!aw daes nof cpply�o an ownrr of properfy � - � � who 6ullds or improves Ihereon, ond who doos suth , ,. , , . • -�� . � work hlmsell provided�hot such lmprovemenls ore no1 � � � . --(,\�� - � ` • infended or offcrcd for sofe.tl,howcver.ibe building or � .. � . , - improvemenf f;sofd wl�hin one yeo�of mmple}lon,fhe � - ' � ownerbullder wll!havc fhc burden ol proving fhof he did , �y., �,1 .,•�;; � , �,,��-_. , i � no1 buifd or,7mprove for Ihe purposo o(so/e.) ' ❑I,as ov�per of tho-propc;ty,am esclusively con- - - :v�cting with liconsed conhocto•s 4o tonstvcr the projec� . � (Sec.�7044)Busirtess�and,Profesilani Codc�ihc Co�froo � ' ` "' ��for's Llrense!m's does no!opply lo an owner ol property • - - wha 6uilds or lmproves ihercon,and who controc�s!or . ' � ' �' -� such projecfs wi�h a coniracler(sJ licensed porsvanf fo � . � � -� � - � the Conlrocfor's License[owJ.� ' � � � � � ' I am exempt und^r Sec. � � � � 8 6 P.C.tor this recson � � ^ , ` Date . . �. \ ` . . . . . . . . � . - '�.� . . ��.. , _. - Owner ' .� . _ � , ._�, „ _.�.� ._. . . . � INSPECTOR'S NOTES � � �� ' � � � ' � ; • . ._ _ �. ' .'c` ' . ' '\ ' . ... .. . - _. _. 1 ' "� . ..