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HomeMy WebLinkAbout1319A (7) WORKERS'COMPENSATION DECLARATION �./^/ ��.,���� � APPLICATION FOR PERMIT � � I hereby afflrm ihm I have a certificate of consent to self V�{� ,/O insure,or a certificate of Workers'Co nsation Ins once, �A��L!%"'�' '� HEATING �- VENTILATING - AIR CONDITIONING G . or a ceri�jf���y+f,(Sr�.3800, a .C. _ _. , . / CF-818(REV.10i81) Polity N ^ �pany �/� . COUNTY Of LO$ANGEIES . BUILDING AND SAFETY�' Certified aopy is hereby iurnishe . Cenified topy is filed wi�h tha county building insp c- FOR APPLICANT TO FILL IN BUILDIN � 1i epa e (P21N7 OR TYPE ONLV) ADDRES Dale plicant , LOCAUiY . NO. TYPE OF APPLIANCE OR EOUIPMENT - FEE CERTIFICATE OF EXEMPTION FR M WORKERS' NEARE57 COMPENSATION INSURANCE CROSS 5T. (Thi�sactioe nwd not ba complal�d ti th�work involvad by ABSORPTION IJNiT,BTtI DISTRiQ NO. � VROCF u ar� fhe permlf la for en�hundr�d dollars(5100)or laa:.) �� � I certify thot in 1he performonte of ihe work for which Ihis AIR HANDLING UNIT,CFM � permit is issued,I shpll not employ any person in pny monner �"'`'—� so as lo become subject b�he Worken'Compensation laws. BDILER,BiU qVFROVALS DA1E INSPECTOft'S SIGNATVRE Oote APPlicant COMFRESSOR,BTU ROUGH ��? NOTICE TO APPLICANT: If,.after making ihis Certificafe of VEMRATIONSYS7EM FiNAt �� Eaemption, yav thould become subject lo Ihe Workeri � ��'\ Compensation provisions of the labor Code,you must forth- EVAPpRATIVE COOLER �, . VALIDATION . wilh tomply with such provisions or this permit sholl be � �deemed ra�oked. FueNnce: Fnu G � LICENSED CON7RACTORS DECLARATION FIOOR U 1 hereby affirm thaf I am licensed under provisions of Chopter 9 HEATER: SUSPENDED UNIT_ �(commencing with Secfion 70D0)of Division 3 of the Business ' w � � . and Professions Cod , d license' full force nd effed." � - � ��jJJ] n. License Nomber� lic Clo s� � � � � � s�� ��.ny A ' CJ i � com�a — �; . . . .g o f- ❑ 1 om exempt under Set. �� � . C 9'�� w Plon check fee a N 8.8P.C.fo�this reason - pERM1T ISSUING FEE S •�9•^`J= ? Date: ' TOTAL FEE I 2.0 9—�•5 Signature � � � OWNER-BUIIDER DECIARAT10N PIAN CHECK AVPLICAM � I hereby affirm thot 1 om exempl trom Ihe CoMroUor's license ► . Low for Ihe following reason(Sect�on 7031.5,B�siness and NAME . ' ' Professions Code): . � ❑ I, as owner of the properly, or my employees with ADDRF55 woges as Iheir sole compensalion,will do Ihe work and �� the slruclure is not intended or offered for sale(Section �ITY TEL NO. , � 7044,Bus�ness and Professions Code). - - � OWNER ❑ I,as owner of the proper�y,am ezclusively contwcting �` with licensed cantractors to construcl Ihe project(Seo- qDDRE55 tion 7044,Businesz and Professions Code). CONSTRUCTION tENDING AGENCY � � � NO. I hereby affirm that there is o construdion lending agency for � the performance of the woik for which this permil is issued - �, �pNtRnCT '- ' �� � (Sea 3097,Civ.C.). . . ._ . _ � _ _ • . . A�DRE55 � � . . .. . ' � . � ' _ lender's Name � � - C � - .// ... . . . . Lender's Address SrJ I certify thot I have read thcs applimtion and s�ote Ihaf fhe iICENSE No. C A55 � - . . .. .. _ ...... . ... _. above informoti0n is correct.I agree b comply with oll County ord�nances and S�ate laws reloring to building construction, . � and hereby authorize repr.se atives of this County to enter ' � - � �� , - . --� � upan t ob ve-�e io perty for in�ction purpOse� SEE REVERSE FOR EXPLANATORY LANGUAGE _ . . _ � Signotura of Appli<anl or Agenl Dale�� ' . . . . . .. • . . . . ._� .... . . . . . . '. . , : - �'�, -- ' . , - : s' INS!'ECTOR'S IdOTES OV'JNER-FiUIL�EI'.DEGLARATION . ..'1�-:. ,. �,, � ,, , . . ,... .. . , .;5. . � � ��I-he�eby b?f��rm��.ihaf I c�i e�Amp��from the Con�.octor's �� ' ' ' �' - - ' ' , �1�..Licenso�Lol'a for ihe following re�son (Secnon 703I.5, � ..._.__ ` .... ..__ . \ . . . ___ _ . .. ._ . . - . .-.. ' ,� •`Bu e s and Fin/essions Cod'el:l�ny nty or county whicb - ."� . � .,\� �� ' , ' � � requi es o permlf fo coistruct,aUe�,imp�ove deriroLsh . " �"� ' - - ' ����- �' � - ' � 4• or mpolr�any-sfrucfure, p`r�or�o Jfi lssuonce, olso re� � r'� , \ '.. \,� �� � '' , '�,��,.. � ., -.qulres fhe applicent(or such permii la Tife a signedstalr ��- - � �' � -� - �'� -' � -. � ' � � ment fhat Fv 7s Iicrnsed pursuanl lo fhe provlslons ol fbe ' � ' . � . Confreclor's:Clcrnse Caw�(Chapler 9(mmmenUng wi�h � . �..... ., .._....... -. ....... .. __...._.....___ ... � .. . Seuion 7000J ol Division 3�o/�he eusiness end Proles- � � . , ' , , sions Codef or fhvt he!s�rxem�t�herelrom and�h'c bosis i ' � ' � . . . � - � for fhe alle�cd-ezempfion. Any violctioo o/ Sec7ion i ..__. _ . ____._ _ .' . .. _ � _:._ . _. .'� � . 7031.5 by any appficant lor a permi�subjacls fhe oppli- �� . � . - ' cant fo a dvtl penolfy of not morc fFon fivc hvndred __ . __ ._. _ __ _ _.. . . __. .._ . . . . . ..': - . dallors S500J.: � ' � .. '' - � . � � � `��� .�'' �� 1 ° � 'l �. ''' � l ` ❑I,es owner of the propeny will do thc work,ond� � -� ��- '� � �� - � - � �� -� � ., . 'ihe struUuro is .intended cr offered for salc.-� ' � . no� �� -�-- -- �� �-,"-�- � �'- -�-� �� � - - -� -- - - --- � � � ' �� (Sea)0:4,Bus�nessondProfo<sionsCadc: TheConlrac- - � '� �� � � ror's!(tcnsc Law docs nof oppfy 10 an ovmer of properfy � --� -- �- ��-- � � � who 6uilds or improves Ihereon„ond who does such � .i . ork hlmsrlf provided�nat such improvemenls ore no� � . i� � � ' ����`..� � � - n�endedor'ollcrcdlo.-sofe.H,however,fhebuildingor , . . . . . . improvemenl is sold wNhln one year of comp/elfon,ihc � � - - � � owner-builder wl(1 hnve Ihc burden of praving f6o/ho did - , � nol 6uild ar improve lor�he purpose of sale.J � � �.t�" , '`i. � �` 1 _ .' � . .,��I,as ov+net of tho property,am exdusively con- � � �� � � � ' � �tracting with licensed co�trac�ors to conso-ocr the Froleci � � , .- . � . - - � (Sec.7044)�Bvslness'and Crofessions Codcrihc Comroo � - , � � . � - ''for's�licensc LaW does'na�'apply to on�owner olProperty " . , I, � �- - � � - - . who 6uilds or fmprovrs ihcreon,pr.d who conlracts lor � ' � ' _ � � - � such projecfs wffh a mnfrector(s)1lcensed pvrsuan/fo � � . � � � ffie Conlrallor's Ltccnse Law). � . . . . _ .._ . . . `;. � . . �,�...,..._.'�- .�; . .. __�. ... _ .. _ . _ _.. . , . ..._ .. . . v . , � � � � I am exempi undeF Sec. � . , B&P.C.�for this rcason �^" t. � . . .. , . . . ' . � -- . � - �_ Date � - � ,\ ' � - � . . . � � � � ��. � . � .,\ � ..i��� . Owner � ' � . . - _ � - � • ��. .. . , . -� . . . . i � . . _ -- . �.�.�� �.. .. � . . � , . .. � � ,. . � ..r� � INSPECTOR'S NOTES �--... . - `.�-� .....'�..�...`•.. � �. �. .. � � - _ �,e,- . . . -� , � � � � . . __. _..� . _ . . . ,. ,_ . .��:� � _ ., , � _ � � _ _ ._ . .. _ .. . _. __.. .. :\ �\.., . . -`� _ _ _ + .