Loading...
HomeMy WebLinkAbout1318A WORKERS'COMPENSATIONDECLARATION �:�L'��,;� //?� APPLICATION FOR PERMIT � I hereby affirm that I hove a certificote of consen�to self C�J '> insure,or a certifimte of Workeri Cam nsation Ins ro ce, y��� . -HEATING = VENTILATING - AIR CONDITIONING !� or a�ertif�G.1�F�Y�, � .. . ..�. . � . . � CE-818�REV.10/81� � Polic No � m an � �/ r � � Certified copy is hereby furnish COUN7Y OF LOS ANGELES BUILDING AND SAFET Certifled topy�s filed with the cou�ty bolldi�g ins FOR APPLICANT TO FILL IN eui�ow ,�'^j r �� ti0 d-parfine �FRINT OR 7YPE ONLY) noozes h_. Dole ppiicant LOCAUiv . NO. TYPE OF APCIIANCE OR EOUIPMENT , FEE CERTIFICATE Of EXEMPTION FR M WORKERS' NEnaESi COMPENSATION INSURANCE � CROSS ST. (Thif�xtfon n�ed not be completad if 1ha wark inrolred 6y ABSORPTION UNIT,BTU oiSraiCt No. oao[ o er 1ha p•rmll fs for ona hundrad dollars(�100�or�ess.� AIR HANDLING UNIT,CFM � �- 1 cerfify Iha�in the performance of the work for which this ��,� permit is issued,I sholl not employ any person in any monner gpllE2,BTU so as to become subject ta the Workers'COTPQl150710f1 LOWS. APPROVAlS DATE INSPECTOR'S SIGNATURE Date /+pplicpnt COMPRESSOR,8TU ROUGH NOTICE TO APPLICANT: If, oNer making this Certificate o( VENTIlA710NSVSTEM � FINAI �7 � Exemprion, you should became su6jec� to ihe Workeri � �1 Compensa�ion provisions of�he Labor Code,yoo musr forth- EVAVOaAlive COOiER ' � � VALIDATION . ' � with comply with suth provisions or this permit shell be � tJeemed revoketl. � Fl1RNACE: fAU � G � LICENSED CONTRACTORS DECLARATION FIOOR B u I herehy affirm thof I om licensed u�der provis�ons o(Chopter 9. HEATER: SUSPENDED UNIT�_ z "(commencing wiih Sect�on 7000)of�ivision 3 of the Bus�ness WA � . �� �1:F Fl and Professions Cod my h ns is" foll force a d e a ' >' ry. . . . eg w Ltcense Number l ia Class � t��J r �_ ► J � •5q.75 � com�o� _ •5 9 7 5� � ❑ 1 am exempt under Sec. . . � uVi B.&P.C.for th�s reoson Pldn chetk fee ' I 2 0 9—8 5 � PERMIT ISSUING FEE$ z Oate: Sgnature TOTAL PEE � OWNER-BUILDER DECLARATION PiAN CHECK APPIICAM ' � � I here6y affirm that I am exempi irom Ihe CoNractor's Litense � , . � Law for the following reasan(Section 7031.5,Business and NAME � - � Professions Code): � , ❑ I, as owner of the property, or my employees wi�h /�DRE55 '. . /� wages as lheir sole compensation,will do fhe work and CItY 7EL ND. ' ' � 1' ihe struUure is nm imended or olfered Tor sale(Se�lion � 70a4,Bus�ness ond Professions Code), OWNER ❑ I,as owner of Ihe properly,am ezclusively controcting with licensed coMmdors to�construO the project(Sec- �'�� � tion 7044,Bulines5 and Pf0�es5ion5 Code). � .4DDRESS � CONSTRUCTION LENDING AGENCY pir EL NO. � I hereby affirm thar there is a construUion lend�ng agency(or ihe performance of Ihe work(or which this permit is issued CONTRAC70 �� � � (Sec.3097.Civ.C.). . .. . . � _ A�OflE55 , � � ' � � . . . Lender's Nome � � � ,� Lender's Address � � 5T TE IC. I certify thot I hove reod this applicotion and s1o1e thol the uCENSE NO. ClASS . . . _, . . above information is mrrect.�aqree 10 mmpty with afi Counfy . ordinances and Sta�e laws relating to building mnstrucfion, � �� , and hereby authorize represe tatives of lhis County to enler � � � ��" ��" upon�h above-meniione openy for inspection urpos .�, SEE REVERSE FOR EXPlANA70RY LANGUAGE I Signoiure of Applican�or Agent �ote � � ' - � - - �� �' "-"' - ' '- ' � , ' ... . . . , . .. .i , .. , ... \ I ' , .. , � . � . . . . .-..'... ... . . . . •�. ., .. . .. .. ... . , " � . �_ . . „'' - . �• � . � � � • •- �iN�rECTOR�swoTes OWNE�-6UILDERDECLARA7ION ;, � - , � ., , . ���-' ' - . . . � �' . � '`i h cby af(irm�hoi I�am\e mp�,from���he Contractor's ( '' .� ..� . ,. ..�.'.. �• , ��`. l7censc Gow..lor�Ih-.follewing reascn (Seclion 703L5. .• . . " .� ., �� —��. ....�. ........ . .._�- - � -- . . .. . � sc� eio�dFroir:sro�zCod�)�a�yc�ryor�ou�rywhrch . �\ � ��� �i�; �� � . . �. quv permil to consfrutl,olter,lmprove,demofish. . _. , - � � . � (�' � � � r repalr any'strudurc, prlo��io I�rfswonce, o(so rc- � -" � �. � � '� � � , '� ; . . . ��� �� ;qulresYhe�a�plicdnito�suchpermlf4e�fileoslgpodsfatr � �- - �� - ' ' � ' - � � � - - � - ' ' � men!fhaf he 1s Ilcensed pursocnt fo the provlsions of tfio � ' '� �- �- , Conlratlor's Llccnsr Cow(Choplcr 9(rommenNng wi7h � � � �� �� ���� ��� - �� �� � i ! � �� � i . Secflon 7000f o1 Division 7 of fhe 8usiness ond Prolcs� � � , � � sions CodeJ or fhaf he Is exemp�fhereGom ond�he basls � � ' � � � � " for fhe alleyed exempfion. Any viofo�ion of Set}!on � � � � � � � I � . � 70JI.5 by�ony applicont(or a permi�subjec/s fhe oppli- , _ . __ _ . . _. _.. . _ . , . � �� . , � � � � � cont to a clvil penclly of not more fhan fivo 6undred . . ..._._..._ _ _.._. . .. - � - � ... . . . . . . � , � , �i � dolfars(5500).: � .. . _ . _ _ - - - ��- � � ' � - '1 ❑I,os owne�of�he properry wi�l do rhe work,and , � � � �he siruUure is no�in�evded or offcred for saic. � �^ ��� ' � � (Sec.7044,Ousfness ond Profrssions Code: Tbe CoNroo � . ' � . for's Licensc Low does nof cpply fo an owne�of property . � � who butlds or improves thereon, and wbo does such f\,� �, ;j . . � i work Fimscl/pro��ded fbol such Improvemenfs ore no� _ - ��`7 :--,�, - infendcd or olfcrrd!or solm.1/,howeve;,ihe building or , . ' . . . � . � . - impravemcnl is sold wllb/n one yodr ol compfolion,fhe � � - � owner•6uild=r w!!i hcve�he burden o1 proving�hof ho did , • �, � , not b�(ld or improvo(or the purpose of sole.) � . . e , , J.'. �.., ' _.1 ,. `� 1�,`. � � ' _..�� � -- � � ❑I,os ovmer�ot 1he properly,am exclusively com - � � � e • , � , - � • . _ ' 1ra[tin�with litensed tcr.!racfers io con;truct Ihe projecr � .. _ ','(Sec.7Q94)�,Businesi aqd Fmfe.-sions Code:7he Conlroo � •' � � , � -� �'for'sLlcemelowdovsnbtopplytocn'ownerofproperly . _ � --�� - - who 6u!!ds or lmprovcs fhcreon,and who con�roc�s to� . �-� � � � . ' - � , such projecfs wtth a con7acror(s)licensed pursuont io thc Confrocfori llcensc Low).� ' � - � � � I am exempt`�nder Sec. . � - B&P.C.for this rcason � � .. � � . . . . . -. � �� .4 . Dafe - ' � �`��. . . � . .. . � � , . '. 'Z�\.,.:�;-` .''�` -` ♦ . . � . � � � Owner . . . . .. . l . ! r _ J . � . . , ' � i � _ INSPECTOR'S NOTES " \ \ -;"� _. ---- . . .,. .._, , , _ � _ ' - ' ' " - �: . , _ _ \� • -. � . � ._ �.