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HomeMy WebLinkAbout1320A (7) Y�WORKERS'COMPENSATION DECIARATION � �;�✓��APPLICATION FOR PERMIT � I hereb ffirm that I have a ce�llfico�e of.consent to self � insure,or a ceriifimle of Workers'Compensotion InSuronte, �bA��� . -HEATING - VENTILATING - AIR CONDITIONING or o cerlifi ygy�1 re f ec 3800, .C.) CE-818(REV.10/Sl) PolityNo. ` � any �/r . . � . . . . � Certified copy is hereby fornished. COUNTY OP LOS ANGELES BUILDING AND SAFETY Cenified copy is filed with ihe caunry building ins FOR APPLICANT TO FILL IN Bw�D�N � Iion de 1 (PRINT OR TVPE ONIV) ADDRE Dote�G%Z�PPI ica nt IOCAUTY NO. TV7E OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FR M WORKERS' NEAReST COMPENSATION INSURANCE CROSS Si. (Thfs s«tfon ne�d nol 6�eomplef�d 1(fha work�nvolvod 6y aBSORPTION UNIT,BTU DIStRiCT NO. FR ESSED BV J fhe permil fs for ons hundred dollars(S1D0)or la�s.) Y 1 certify fhat in Ihe performance of the work for which Ihis AIR HANDLING UNIT,CFM � ����` permif is issued,I sholl not employ ony person in any manner gO1LER,BTU ao as to become subjeU to�he Workers'COTPCI15p11011 LOWS. ACPROVAlS �ATE INSPECTOR'$SIGNAiURE Date /+pplicanf � COMPRESSOR,BTU ROUGH y �� NOTICE TO APPLICANT: If, pfler moking this Certifimte of VENTILATION SYSTFM . , fINAL �— /a Eaemption, you should become su6ject to the Workers'. ,'��, Compensation provisions of the lobor Code,you musl forih• evnPORAirve COO�ER VALIDATION � with comply with such provisions or this permit sholl be � � deemed revoked. � FURNACE: FAU Y UCENSED CONTRACTORS DECLARATION - FIOOR BTU I hereby affirm fhaf I am licensed under provisions of Chapter 9 HEATER: Sl1SPENDEO UNIT_ � � �(tommencinq with Section 7000)of Division 3 of�he 8usiness A�� . and Professions Co e nd ice s in full fo¢e d eHeO. ' } a License Number� c.Clpss ► O �'/ �� J2.�Fl � Cool�cc v ` �ofe - - �,!• • • • •� v ❑ I am exempl under Sec. � � � + •6�.7_5 y Plan check fee B.&P.C.for this reason� . y PERMIT ISSUING FEE S • • °E��r� � Dote: ' TOTAL FEE �Z p q—g� Signalure OWNER-BUILDER�ECLARATION PIAN CHECK APPLICANT ' . � I hereby offirm Ihat I om eaempt from the ContraUor's Lirense , Law for Ihe following reason(Sectian 7031.5,Business and NAME Professions Code]: � ❑ I, a5 owner of Ihe property, or my employees wilh ADDRESS ' . woges as their sole compensation,will do�he wark and CITY TEI.NO. � Ihe structure is not intended or offered for sale(Section 70d4,Business ond Prafessions Code). OWNER � ❑ I,as owner of Ihe property,om exclusively contracling � � with licensed coNroctors to construct the project(Sec- '��� � ' � � tion 7044,Business ond Professions Code). ADDRESS CONSTRUCTION IENDING AGENCY � � i I hereby affirm that there is a construtfion lending agenty for , Ihe performance of the work for which�his permit is issued CONTaa.CTOR � - - (Sec.3097,Civ.C.). . .� .. .... . ADDRE55 -� � � � � - � Lender'S Name lender's Address '/ / � - 5 ATE LIC. I certify Ihat I hove read this applicotion ond stote that ihe IICENSE NO. CLA55 � � � _ � � - � - � � above information is torrect.I agree to comply wilh oll Coumy ordinonces and Slate laws reloting to boilding consiruclion, � �� and hereby authorize repre eMalives of Ihis County to enter � . - � upon t above-m N' ne operty for in��n purpo�_ � SEE REVERSE FOR EXPLANATORY IANGUAGE r�� <JiJ Signolure of Appilcon�or Agent Doie � •1 r , .. ; � (, � , . , •..... . .�,. .. ,. ..,. . . ..._ - - ' - �IN3tECTOR'S NOTES OWNER-GUILD�R DECLARATION � �. ,, - , ` . i�. ' ��,.• � I'•hereby affirrti�ho!I om exempt from�tFie Conlraclar's ',) � ' ' ' ' " � � . �,licen;r �ow for the followin9 reoaon (SecNon 7031.5. _._, ... - . '.. ...._ ... . . . ..__.... .. . _ ..._ _._.. . . .__._ . _.._. .._ _. . .. _ ... ' ' , .. .. . Ous+ness'bnd Frolnssicns CodeJ�Any elty or coun}y whkh �^ ..\ � �„���, � _ ('��-,� � , requires c permi�fo mnslrud,alter,Improve,domolizh, ' •' - ���'� � - ' � � -- � � �� � ,or�repvir cny sfru[ture. prior,tpJts,lssvonco, olso re- � � , �,,�`',_ � � �, _ . _ _ � quires�fReapp(icvnt/orsuchpermil}oftleosignedstafo- � -"� -"- "" -" � ' ' ��` ' - - �-- ' � menl lh'at Fe is(kensedpursucnf fo Ibe provlsfons o(the ' _ Confractor's Gicense!cw(Chop3er 9(commenting wilh ' "'�"'��"' "�" �"" ' ` "' '� "�"' " , ' ' � � '� � ' -' Sect/an 7000)of Divislon 3 0l,16c 6usiness ond Proles- ; � ' .. �, � sions Cade)or Ihat he Is exemp�.fBerc/rom and the ticsis � , � ' lor the olleped�e empfioa Flny violation of Sec�ion . -. _ .._. __ _ _ .. . . __ . . � , . . 703I.5 by ony applicont lor a permi}subjecfs}he oppli- , � . , � cant lo o riv'r!penofty o{nof.more fhcn iivc hundred ,. ---. . __. . - - . -. . ,"\ ' . ; . , , � . , dollars(SSOoJ.: �� � � '� ' �� � � ' ❑I,cs owner of tho properiy will do Ihe work,and � . . � - - -.. _.. - - .: - -- -, . ..._ . ' .. � � �� t �thc structurc is nol Wended or oifcrad for solc. ', �� � �- -- � � - . -� � ' ' (Sec7044,BuslnesspndProlessionsCodc: iheContrao � , �; � � , , . tor's Citensc Law does noi oppfy fo on ovmer of properry - - � � � ' � ' • �� who butlds or improves fhcm.on, and who does such � . • � t,' ; � ` . , work b�mscl!provided tBal such improveme.Ms ore no� .�� � �-.1 ' inlended or oHcred/or sale.lf,however,�he bWldfng cr . . . , . lmprovement is sold wilhin one yvar of compleHon,��he . � t � � � � owne�•bpilder wtlf have/he burden of proving�haf ho did � ..i_ . __ � � —� • _ , not 6uifd or improve for the purposo of sale.)� ' � �, � _ - -� � � � - ' � � ❑I,as owner o4 ihe p�operty,am exclusively con- � � , ' nocting with li�ensed controctors to conz7rucr the pFoje:t - - ..(S�c.704-0)6usir.ets ond Pro�e3sions,Code�ThrConf�oc- � � ` ' � � � � '���-tor's Licrnsc!ow docs no�apply fo en ownbrofproperly - �� i:� - ' - � who bullds or Improvcs fhcreon,and who confroUs lor i ' -� � such projects wi}6 c tontroctor(s)licensed pvrsuanl to . ' ' ' � -fhe Ccntrcctor's llccnsc CawJ.' � . �'-'.1�,�� � _ . _ . . . . . . . _ . . . � i ., _ • � � � I am exempt under Sec. ' � 6 8 P.C.for lhis reason � � � � . - l,.i - . - . Dote . ' \'. ' _ . `.. ,y.'• . .. . . , . � - , � . . Owner .. L_ -'� . , `�- , .. � . INSPECTOR'S NOTES '• • - - , . ,\ _' _ ` _ 'i-'- , ' t _ ,.... \, . , . � , . .. . . \ '�' �