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
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Signolure of Appilcon�or Agent Doie �
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- ' - �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
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-� � 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 �
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� � . - l,.i - . - . Dote .
' \'. ' _ . `.. ,y.'• . .. .
. , . � - , � . . Owner
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INSPECTOR'S NOTES '• • - - , . ,\ _' _ `
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