HomeMy WebLinkAbout1323A (7) WORKERS'COMPENSATION OECIARATION qpp�ICATION FOR PERMIT
I here6y affirm �hat I have a certilicale of conseM lo self �����JG�� �
insure,or a tertificate of Workers'Com nsation In urance, �
or o certifi � � r/s�e�.saoo, �bA�c . - �HEATING�• VENiIIATING - AIR CONDITIONING � 1�
[f' CE-818 REV.10.'81)
Po�icy No. � r cQ�*��nY ( . . . - .
� Certified copy is hereby fumish d. �f COUNTY OF LOS ANGELES BUIlDING AND SAFE7Y
Certii�ied copy is filed with the covnry building ins eo- FOR APPLICAN7 70 FllL IN � swtoiN
' n de f nt. ADDRES
� � (PRINT OR TYPE ONIY)
Da APPl�mnt LOCnUtY +
NO. TYPE OF APPIIANCE OR E4UIPMENT FEE
CERTIFICATE OF EXEMPTION F OM N/ORKERS' NEnRE57
COMPENSATION INSURANCE � CRO55 5T.
(Thls t�ction naod no}bs complN�d if fho work�nvolved by A850RFilON UNIT,BTU oisiRicr Ha. , oa ss[o ar \
, ih�p�rmil�t for ona h�ndnd doflon(;IOO)or(ess.) � �
I ceriify fhat in fhe performpnce of the wo�k for wh�ch th�s .41R HANDLING UNIT,CFM ��
permir is issoed,I shatl aot employ ony person in any manner ��/
so as to become svbject to fhe Workers'Compensation Laws. BOUER,BTU nvvaovnis' onre INS�ECTOR'S SIGNA7l1RE
Dale ePPlicoN COMPRESSOR.BTU ROUGH �^7 y/ 1�/.� .
NO710E TO APPLICANi: Il, after making this Cer�ifimte of vEMItqTIONSY57EM FINAI
Examplion, you shoald become su6ject to the Workers' �
Compensofion provi5ions of Ihe Lobor Code,you must forlh- EVA�RATIYE COOIER '� \!/{��p/+T�pf� �
witb [omply with such provisions or this permit sholl be ` � �
deemed revoked. FUkNnCE: FAU ��
� LICENSED CONTRACTOR$DECLARATION fIOOR B�
�I hereby affirm thol I pm licensed under provisions of Chopte�9 HEATER: SUSPENDE� UNIT ���
'(mmmencing with Settion 7000)of Division 3 of the Business W tL �
ond Professions Code my fc�ns/ed�'sjw�(�ill force and effecL y
��(� a
Licensa Number Lfc.CI s ► ' �
r .'�1 3 2 3 P, �
C
com�a �, a . . . .g o
❑ 1 am exempt under Sec. ,� W
8.8P.C.for ihis reason Plpn thetk fee I • •�B 5� y
PERMIT ISSUING FEE S ' e h^,5(1? ?
Dote: ' "
5gna�ure TOTAL FEE 1 2.'J 9—R,r�
� OWNER-BUILDER DECIARATION PIAN CHECK A7pUCANT � .
I hereby aifirm that I am exemp�from Ihe Contratlor's License , �
Law for the following reason(Section 7031.5, Bosiness and NnMe . � �
Pro(essions CodeJ: � .
❑ I, os owner of the praperty, or my employees with ADDRESS . '
� wages as�heir sole compensation,will do�he work and ��T� TEL NO. r��
Ihe structvre is no�iNended or oifered for:ale�Section � ' .
7044,Business and Professions Code).
� OWNE
I,os owner oi Ihe property,om exclusively conlracting
wiih I�censed conlractors fo consrruci the projeU(Sec- ''��� '
fion 7044,Business and Professians Code). ADDRE55 �� .
CONSiRUCTION IENDING AGENCY HO
I hereby affirm that there is o construction lending agenq for �
the performonce of the work for which Ihis permir is issued COMRaCTOR �
(Sec.J097,Civ.C.). �
. Lender's Name ADDRESS � . . � � �
� NO.
lende�'s Address � � �� _
ST iE LIC.
I certify thoi I hove read Ihis applimrion and state thdt�he LICENSE NO. CLA55 �
obove informo�ion is conecl.i ogree 10 comply wilh all CovMy "' ' � - - - - �
ordinances and State lows relating to building consrruction, �� ,
ond hereby authorize epresentoiives of this CouMy lo enter � � . ' � � .- . .
upon t above-memio d ro erty for inspec�iun pvrposes.. SEE REVERSE FOR EXPLANATORY LANGUAGE
��y--������ /��--�- ;
S�qnarore df Applfcom or Agen� Do�e - . . . . . .,. . � . . .. . . .
� .
�i �._. , � : � . ' : , c; .� . �.�
" � ' - IN�fECTOR'S NOTEs , , OWNER-6UILDER DECLAF:ATION
. . � ' ``I hre6y offirm'thot I`om exrmpt fromJthe Coniro<1or's
.r . .. ..�. .- .. . ._ ... _._ . .._.... . _ . ., ._Bcensc�d��r{hefoloCw�g (5�71 7091.5.
. �,-' L � t I i reoson ec on
, ��, " � � us ness an ro esvons o eJ:Any cify o�coun�y which
. � ���� ' �� _ . . . requlres a perm'r�lo ronsttucL olter,Improve,demolish.
• � �. r.�'�� ��.'", t � - -, , ' � ' �, �•pr repalr any•s��uc�ure, prior io:ffs {ssucnro,;afso re-
�.... . �.;.
� ,
� -"`"�� ,�� -�•'- � � � `���� � . '�','� _��qulres ihe op;icont/or such perm?t�o Tile a signed sfofe-
�. . .
� ' �� � � � " " - . � � � � mvnt fhat hc I liceosedpursuont�fo Ihe provislons of fhe
� _ �� ' Con�raUor's Ctcensc Law(Chap�er 9(commencing wlth
� y � � � SeUion 700'�)o�Division 3 0l fhe l3usiness ond Pro(es-
' �, � - ' '"sions Code)a�tha�he i;exempt ihercGom'ond Ibe basls
� . . � - - � � ' � for Ihe eNeged e emp�ion. Any violafion,o!Sedion
� i -�� --- � � � � - - --- � � �-- . � �7031.5 by any apphconf/or a permil iubJecfs thc appli-
�� � � � canf to a cNil penalty o/nol more than�ive hundred
— Y ..
�-�-.." . -. -.. . . .. . .- . dolbrs(S500J.: �
_ _ __._ _ ' � ' .�. '�� �'; i �' . '•..: -' .:, .'-''' 1 t ❑I,os o�.vnr o(thc property will do the work,ond
..
� � , ' � ' � , � �, . ,., . " �he struc�urc is not iNended or.offcred}or sate. '
��`"--- ' " "- � ' � � - �-�� � �- � ' � � (Sec.7044,!luslness and Pro(essions Code: The Contrao
_ _ , , � , �, for's llcense Low does not apply fo an owner of propeNy
� � wbe bullas or improves fhcraan, and who doos such
� � . t�•��•, � � work himscl?provided�hor surb improvemen�s are no�
) � � inlendedorbffcredlarsole.H,however.lhebu7fdin�or
' � . - - � improvemenf is sold wilbin one yeor of completion,fhe
' - � owner�buifder wlf!have fhe burden ol proving Ihoi hc did
' ' _��� + �� �- ' not buifd or improve fnr fFe purposo o(�ole.) ��
i. �. 'i i 1 -,- � . .
, - • � ❑I,os ovdper of.the propqrtY,am exdusively mn-
• , � . , ,�La�tmg with li�ensed cen•rac�crrro consir�ct the project
� - _ ,'ISec Y044)6oslrtess�ond Professiops Codm The CoMrcc-
. - ��tor's Liecnse'Lawdoes-no�oppfy Idan owner ol property
� , ' - who builds or Improves}hereon,end who roNrocts for
� � � such projects wilh a con��vetor(s)licer.sed pursoant 10
� • - - the Conl;oclols Gcense Lav�). �
.. . �'�.• . _ . _ _ _ . . � . . _ . . .
. � ' � I am exempl under Sec.'
� � B 8 P.C.�for this rcason � �
�.
_._t . , ' Date ' .. . ,. _ .
, _ \:
� - ' :�� . � � � �,��. �. �� . ., � . � � .
'. � � i Owner
, i , '� ` " , ,.
INSPECTQP.'S NOTES � . . .. . ^ . ��-,, ��'' . :=,�\ • 1 . . � . .
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., '♦ _ .� . _ . � . �'.\; . .
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