HomeMy WebLinkAbout1324A (7) - WORKERS'COMPENSATIONDECLARATION ����� APPUCATION FOR PERMIT � ��
I hereby affirm thai I have a ter�ifim�e of consent to self �'�
insure,or a certificaie of Workers'Com nsation Ins r nce, �G�� � HEATING • VENTILATING - AIR CONDITIONING �
or o�ertif' o f�(�3800, 76A364C � .. .
CCE- IB(REV.l0�8i1
volic N a� � � COUNTY OF LOS ANGELES BUILDING AND SAFETY�
� Cerlified copy is hereby furnishe . � �
Certified copy is f�led with the county buildin in e FOR APPLICANT TO FILL IN BUIIDIN
�ion de art �. AODRE ,.
��(Z� (PRIN7 OR TYPE ONLY1
Date ApplitaM LOCALtTY
NO. TYPE OF APPLIANCE OR EOUIPMENT FEE
CERTIF�CATE OF EXEMP110N OM WORKERS' NEAREST
' COMPENSATION INSURANCE CRO55 ST.
(Thti's•dion n•.d no�ba compb�.d�f fh•work involvad by ABSORPTION UNIT,BTU oisraicr r�o. P E55ED r
tha p�rmit Is for on�hundr�d dollars(5100)ar less.) � qIR HANDLING UNI7,�CFM � •
I certify fhat in the per{ormance of the work far which Ihis Qt�✓�
- permir is issued,I sholl not employ any person in any monner BOIIER,BTU
so as�o become subject to Ihe Workers'Compensafion LOwS. APPROVALS DAIE INSFECfOR'S SIGNATVRE'
COMPRESSOR,BTU ROUGH ���te �
Dare - Applimnt � �
NOTICE TO APPUCANT: If, afier making Ihis Certificote of VENTiW.tION SYSTEM FINAL � �
Ezemp�ion, you should-hecome subjecf to ihe Workers' . , �,1
Compensation provisions of�he Labor Code,you must forth- EvnaORntivE COO�ER VALIDATION
with tompiy wilh such provisions or this permit sholl be
deemed�evoked. � FURNACE: FAU TY
UCENSED CONTRACTORS DECLARATION � FIOOR e U
I hereby aifirm Ihat I am licensed under provisions of Chapter 9 HEAiER: SUSPENDED UNIT__
'(tommencing with Section 7000)of Division 3 of Ihe Business W « .�.
and Professions Code,on my lic nse i/s inj Ifull force and ef^fect�. ' � �-� 5�4 f� O
License Number-�'��ys�""Classl� . ► ��e a . e . s� V
C
� .� � • •J9�5 �
conlro V
O � . .. • o e �i n�]f r u
I am exempt under Sec Plan check fee vi
B.BP.C.for ihis reason PERMIT ISSUING FEE S �C.G 9—`j 5 �
Date:
TOTAL FEE
Signoture �
OWNER-BUILDER DECLARATION PLAN CHECK APPLICAM
I hereby aFfirm thal I am exempt from Ihe CoMroctor's License , � ,
Low for�he following reason(Settion 7031.5,Business and NAME �
Professions Code): - �
ADDRE55 ^
❑ I, os owner of 1he property, or my employees wiih � �
wages as their sole compensalion,will do the work and ��TY TEL.NO. .
the strvU�re is nor intended or offered for sale(Seclion
7044,Business and Professions Code). � � � OwNER �
❑ I,as owner of�he properiy,am extlusively conrrac�in9 MAIL
wifh licensed coMraclors to tonstruct the projecf(Seo- qDORE55
� tion 7044,Business and Professions CodeJ. �
CONSTRUCTION IENDING AGENCY Et.NO.� �. .
I hereby affirm that there is a conslruclion lending pgency for �
ihe performance of ihe work for which this permit is issued CONTRAC?O � -� _ . . , . .
(Sec.3097,Civ.C.). � . � .
. ADDRESS - � �
Lender's Name � '
. O.. . _ . . . .
lender's Address �
5 iE �•
I cerlify ihat I have read Ihis applimtion and sb�e Ihot ihe LICENSE NO. CLASS � —� � � - - - - - � �
a6ave information is correct.I ogree 10 comply with all County , . �
ordinonces and Stale laws reloting to bullding consiruUion, . . . . . . . . . . .. � . .
and hereby authorize represe ioiives of this Coonty to enter . -
up�above- e io d pert for ins edion purp s. � SEE REVERSE F�R EXPLANATORY LANGUAGE . . .- . _
Signoiur i Appiiwnt or Agenr Da�a .
. . ... � . • ' . ... �, �. � �;'\ � . . � . : . � �
�
• �7�
. .. . , , . : � WNEF-uUIIDER DECL4RATION
. _ , . . ,,.,.. INSrECTO�'S NOTES � .. . . �
� �
. . . ' 1 �.'�!herek�y a.`(irm.thor I am exemp�.from the.Conlroctor's
y ,� ,. -� ... � 1��. •- . -���icensc.16:v�(er Ihe foilowlnq reoson �Seclion 7031.5.
;� ._ .._. _ .... __. __...- ' ' �' � ' y h h
.. . .._ ._ ._. _ . . _.. _ .. ., ..._ � r unt w ic
�, ��,1�\ �,�. ; � l.� ... ,�� . . _ .�.� . . . •.�Bequtresa�Foi�foScemCodi.IclAier�Impr vo demofish.
� � _ ���,��_ .��' i , , � , � t 'er rrpoir any`strudurc p lorta its��issuance, aho re-
' _ -\\\ \ �l�: ... . . . . , . ,'� qotrra fhe eppli;ant for such pormJt fo file a siqned s�ate�
� __ ____ �` _., :,,.� ., . , � '- ' � � meM Ihcl he 7s licenscd p�rsuanl fo�fhe prov/slons of the
. � , . . � Canlractar'z LIcCnSF Lav.�{Chapter 9(commcncing wlfh
!,..._ ._.,_ .. .. .. ...__. _.. ._. - .. . _ - . , � � � � ScUion 7QOOf ol�ivis�on 3 of fhc Euslness and,Pro�es-
� . � � �sions Cude)oNn�t he is e�xcinpi fhere/rom ond Ihe 6osis
I � . � . �� � �or th�e alleged exemp;ion. Any�violafion of SecNon
I - I. - '. . � "703L5 by ony oppiicenl for o permll subjecfs fhe oppli�
�-� -� �— —-� � -�� - - �-� -- "--� � - - ' ' , . � canf lo o civiL p^nalty oF nof more than five hundred
.--. - — . . . _. . , -_--- �_ . � dollars(5500).� �
� , . , �• \\ " . �_ � . . , �i,as o•n�ner eF�he property will do the work,ond
... .. - . ' � ��- � � - the strucwre�i:nol inicnded oroffered for sala�
�� � � � �' � � , (SeC.7044,Buslness ond Frolcssions Code: The Confrac �
. �- -- � - � � . ,, io�'s lJtense Lav+does nof ooply fo an oivner of property ,
_ .. . �� �_ � �� . . who bWlds or.improvcs thc�eon, ond who does such
����-" � � � � work h�mself provfded tho!such fmprovemenls are nol '
� ' ��j . � ' � intended or o(fered for sole.If,howwer,fhe building or �
. . . , � improvcncnl Is sold wilh/n one ycar of compleHon,I'ne
� . . � � o�,vner•buifder�vi;f Aove Ihe burdon of proving IFaf ho did
� . � _ . .. ��.; __._ noi build or Improve for Ihe purpose ol safe.) � '
' ` . �� �1 `'�..J <- � .;, � .- . ❑i,es ovmcr of ino property,am exclusively com.
, . , . ..tr�cting wilh lic^nsed cor.troctors lo-cc.^.ciruU Ihc pro;=ct �
;.(Sec,%Obd!BuslnMs.pnd�Prc�cssYonz Codc:-Thc Conlror
. '� � � - � ror's License Lcw does no�apply�to an owner af property
� � � . wba boilds ar Improves thcreon,and who mntracts for
� ' � � . . , euch projecfs wifh a tonf�ador(s)licert,ed pursuont�o
. � .. . .._. _ ._ .
` ... � thc Contrcctor':Licensc Law).
� . . .. _ .. _ . . .. ._ .
- � � - � I om exempr under Scc.
B&P.C.for Ihis rcason -
� . . . � : ��. � . . , . . . . ., . . .
: ... . _ . ., � Daie , ..
. � �_ •� '. . Owner . . . � �
'. .�- -. � ... �. .�.
. .•� . � . . . � �. � . �'�' .
` .,'. _... � � ' � � . _ - �. . ... .� � . .. , .. .. ., . .
. _.. _ .` . ' � , .�:��`..�.�_.�. - - -� . . � . . � . . -
INSPECTOR'S NOTES �
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