HomeMy WebLinkAbout1325A WORKERS'COMPENSATION DECLARATION _ n�V�/ //�APPLICATION FOR PERMIT �
I here6y affirm that I have a certificate of cansent to self ��/ .�/nLI �
insure,or o certificate oi Workers'Compensation Ins�rance, (r ���� � EATING - VENTILATING - AIR CONDITIONING
oro certiti 36 a6.C.) 76A364C �. .
� CE• 8(REV.IO/81)
Policy No m any �/� ��
� Certified copy�s here6y furnished. COUNTY OP LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with ihe couMy building insp c• FOR APPLICANT TO FILL IN su�to�N .
tio ep me (PRINT OR TYPE ONLY) ADDRES
�ate ppliconl �' . IOCALI7Y
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF E%EMPTION FR M WORKERS' NEAREST ,
COMPENSATION INSURANCE � CRO55 Si.
(This s�ction n��d nof b�compbbd if 1h�wo�k involwd 6y Ag50RPTION UNIT,BTU DRIRiQ NO. iR seo ep
th�p�rmit li for one hundr�d dollars(5100)or lass.) qIR HANDLING UNIT,CFM � /
1 cer�iiy�lhat in the performonce of the work for which this ��y�
permii is issued,1 shall no1 employ any person in any monner gO1LER,BTU
so as lo become subject to Ihe Workers'CORIPCOSOfiOO LOWS. � AVPROVALS oare INSVECiOF'S SIGNATURE
Da1e Applicanl COMPRESSOR,BTU ROUGH :�� �—G
NOTICE TO APPLICANT: If, after making Ihis CertifiCate of VENTIIATION SVSTEM ' FINAI � .
Exemplion, you should become su6ject 10 Ihe Workers' ��
Compensotion provisions of ihe Lobor Code,you must forth- EVAPORATIVE COOLER VALIDATION �
wilh comply with such provisions ar this permif shall be
deemed revoked. FURNACE: FAU G Y
LICENSED CONTRARORS�ECLARATION FLOOR TU
I hereby affi�m that I am I�censed under provisions of Chapter 9 HEnTER: SU57ENDED UNiT_ �
��commencing with Section 7000)of Division 3 of the Buziness W ��
and Professions Cod d m li en full force and effect. - }
°/ a
License Number_�ZJ ��� ic.CI s . , � O
:"� J2.�(t pe
Confra� - �; e . e •E, �
❑ I am exempt under Sec. . . V
- Plan check fee • I � •b F�5 0 �
a
B.BP.C.for Ihis reason� � �
PERMIT ISSUING FEE S � � �E�u'�C= �
Da�e:
TOTAL FEE I 2,C 9—F 5
. Signolure �
� OWNER-BUILDER DECLARATION PIAN CHECK APPLICANT
I hereby affirm thot I om ezempt Trom the CoNracfor's License . . , ' '
lpw for the following reason(Seclion 7031.5,Business and NAME �
Professions Code): �
❑ I, as owner af ihe properly, or my employees wi�h ADDRE55 �
wages as iheir sole mmpensation,will do Ihe work and • �^�
�ihe struct�re is not intended or offered for sale(Secfion CITY TEL.NO.
7044,Business and Professions Code). OWNER �
❑ I,os owner of the property,am exdusively contracting �
with licensed coNracrors m construct�he project(Sec- r'�'�� �
� tion 7044,Business and Professions Code). ADDRE55 /
CONSTRUC710N LENDiNG AGENCY i .No.
I hereby affirm lhat�here is a tons7roction lending agency for �
1he performonce of Ihe work for which fhis permh is issued CONTRAC70R � "' .
(Sec.3097,Civ.C.). � � � --. .-. . .
ADDRESS - � - �
Lender i Name
O.
.Lender's Address '
I ceriify that I have read this appiicatian and state tha�Ihe t E LiC.
UCENSE NO. �CLA55
obove informotion is coveU.I agree b comply with oll County . .
ordinances and Stale laws reloling to building consiruction, . . , , , . ., . _ .
ond hereby authorize re resentaiives of�his Counfy to enier '
upon� o a ove- e ti e ro erty for i�peUio�pose�.,�� ;SEE REVERSE FOR EXPLANATORY LANGUAGE �
� ��j
Signo�u �Appliconl or Agenr Daie . . .
. - �r: _ . .. . .. . _ • , . . ' . ,
. . ...� .. . ., . '' � . . . . t ,..\`��_ �'— ' . ' • ' � '. , - . .
' " • - INSl�ECTOR'S NOTES " OWNEF:-6UILDER DECLARATION
�r . , � l. .
� - . - - • ,t�, ,I�h rehy offi m�fhaf I�am empt1fro 16e Conhodor's
� ' - � ' � '� " �� '��� - � • ;�Ucense low�for-fhe follow ng reoson (Secfion J037,5,
� . _.ti_ .. ._.!.;.. . ... ... ... .. '. ._ ._. _ ...._ .. .. . _.. _..' 6usiness and Proless7orts Code):Any cify�or coun}y wMch
� � ��t � • . ,- , ',��� . � - -� �requlres apermii Io construcl,aller.�lmp�ovc,dcmolish,
' �"�� -� � -" -- '� ' � � ',or repolr�any siru.-fure, prior��o ifs lssvance, olso rr
� '" � �� � �� � �:qufros Ihc ayplicant lar such permf(to file a s�gned s/ole-
_... _ _ _.. ._•,.: . ,. � 't.i : .. ._ .._ ._ ' . . . .. .. . . , . .' . .. '.. _ . .. _ .
�. . � mcnf fhot he Is licansod pursucrtl to�he provis7ons of Ihe '
� � -� . . Confrodor's Liccnse Lew(Chopfer 9(commenUng wNh
�'����������� ��"� �� �" --��-�- �' " � '���� ' ' - �� � � � Secfion�OOOJ,o(Divislon 3 of}hc Gusiness and Prolos-
' � � , . � ' sions Code)or Ihcf h�!s exemp!Ihem/rom ond�he bcsls
� � � - � � � Ior the oqegcd exemption. Any violofion�of�5ection
�' _-_ .- .. '.' ._ _ .: _ _._... �. ... ;'� . . , 7031.5 6y eny applicanl for o permll iub(ecfs fhe oppl4
. ' �� . . �� � � �� - " ' � caN ro a dvi9 penolfy of nof more than five hundred
'� l . .___._. _.. .. . . . . . `.�• .. .'., .,': ..! '._,... :� d (5500).: � � �
� ',� ., - -�-- - � �• � � , � �'la[i I,os owner of thc property will do thc work,and
- �he struclure is not intendcd or.offered for sale. �
�--- - �--- -� ' �� � - --- �� , ' � � � � � � (Sec.704-0,Eusiness ondProfesslons Code: TheContrac-
� '" ' � �tar's license Law does nat cpply to an owner oF property
� � � � ' � � � who 6ulfds or improves �heraon, end who does such
. � .,�� .. . work hi�+,soH prov�dcJ fhaf such 7mprovemen�s ore no�
,� � " �� � � t � inlended or offered 1or sole.IL Fowcver,Ihc 6uifding or
. � . . . �. Improvemonf is sold wflhln one ycor of complefion,ihc
�- � owner•6uilder w(fI have Ihe 6urden of proving 1ha}he did
� '_ � ,1; � - ._ �y no�6ulfd or improve foc,fhe purpase ol sala.) '
� � � � �---�-i - � � �' •, ❑I,as owner of thc ro er
. ' p p N,am exclusively con-
�, . , ' �tracting�vith liccr.s^�c6ntrcc7ors to canshuct thc proj�ct
� �� ��� ' (5'ec.7044)Buslness aad Pro/essions,Ccde�The Conlrac
� � � . �' - for's L(cense Lawdoei naf opply fo an ownero7property
. � - who buifds or Improves thereon,and who coMracfs for
� � . ' ' - �' such projeus wflS e coNra[lor(s)licensed pursuan�to
� � - . ' - - � - Ihe Con�roc}or's Llcense Law). �
,`_..
.. i '�t_. , � . . . . . .. . _ . _. . . ..
. � � � I am exemp�under Sec.
� 8&P.C.for this rcason
. -•- ---._ . ._..... . _. .. . . . .
:,� � " - � -. � • ', �� `• � . Date . .
. . " � ��', \\' ��\�'. ' . . Owner � . .
i _ _ . . .,`_�. .
INSPECTOR'S NOTES , ` ' ',\ `. '.
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