HomeMy WebLinkAbout1321A WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT Y �
I hereby affkm Ihat 1 have a certificaie of consent to self � � .
insure,or a certiticare of Workers'Compensation Insurance, �bA764C �� • HEATING - VENiIIATING - AIR CONDITIONING (f
or a cerlifie � f c.3600, .C.) . � . _ , _,
' CE•918(REV.10/81�
P�o�ity No. C npany . . ..
Certified copy is hereby furnished.
' � ' COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed w�ih the touNy building ins eo- POR APPLICANT TO FILL IN, su�iD�NG
tion de artm nt. ADORE55
(7RINT OR TYPE ONLY)
Date Applimnt IOCAU7Y
NO. TYPE OF APFLIANCE OR EOUIPN�ENT � FEE
CERTIFICATE OF EXEMP710N F M WORKERS' NEARE57
COMPENSATION INSURANCE CRO55 Si.
(Thls s�etlon nasd not ba eomplo4od if fh�work Involved by ABSORPTION UNIT,�BTU DISiRiCt NO. PR sseo av�
fhe permft it for one hundr�d dollars(SI00)or la«.) �
1 tertify Ihat in the performonce of Ihe work for which this NIR HANDLING UNIT,CFM � 2���-
permit is issued,I shall nof employ any person in ony manner gpILER,BTU
so as to become subjed b the Workers'Compensafon laws. nvrzovnts oate INSPECTOR'S SIGNATURE
Dafe Applimnt COMCRESSOR,BTV ROUGH � ���
NOTICE TO APPIICANT: If, after making Ihis Certifim�e�of VENTILATION SYS7EM FiNAL o�i .�f2� '
Exemption, yoo shauld become subjec� to ihe Worke�s'. . �� "
Compensation provisions of the Lobor Code,you muit forth- EVAPORATIVE COOIER . VALIDATION �
wi�h comply with such provisions or this permlt shall�be
� deemed revoked � FURNACE: FAU � GR V
� LICENSED CONTRACTORS DECLARATION FlOOR TU
I hereby af{irm Ihat I am licensed�nder provisions oi Chapler 9 HEA7ER: SUSPENDED UNIT_
'(commencing with Section 7000)of Division 3 of ihe Business �WA«
ond Proiessions Code, n my lic nse is in full farce and effect. �
Licensa Number- .C ss� � , O
�� �'2� A �
Contro � . _ . . ... �(e •'J��.7� �
❑� I om exempf under Sec. . • ° �J(�.'�:)L a
Plan check fee
B.&P.C.for this reason� � . y
PERMIT ISSUING FEE; I 2.0 9-8 S ?
Da�e:
TOTAL FEE
Signature -
OWNER-BUILDER DECLARATION PLAN CHECK APPLICAM ,
I hereby affirm fhpl I pm exempt from the CoMractor's License , ►
law for the following reason(SeUion 7031.5,Business ond NannE '
�Professions Cadc):
❑ I, as owner of the properfy, or my employees wilh ADDRE55 ,
' wages as iheir sole compensalion,will do ihe work and �ITY TEL.NO. ��
the strocture is not intended or affered for sale(Section -
� 7044,Business ond Professions CodeJ. � �
OWNER
� ❑ I,os owner of the property,am extlusively conirptling
wi�h licensed contracrors to construct the project(Sec- �`"A��
tion 7044,Business and Professions Code). � /+ooee55�
CONSTRUQION LENDING AGENCY � �- / .No. �
� I bereby affirm�hat�here is a construction lending ogency for �, �
the performonce of the work for which Ihis permit is issued COMRAQ � ' - �
� (Sec.3097.Civ.C.1. - - -. � .-. . . .. -. .
. . ADDRE55 1 . . . . . . � .. . .. . . . .
' � lender's Name
r r O.
Lender's Address J �
5 A UC.
� I certify thar I have read this applico�ion and stote thai the UCeNse No. an55 - - - - - - - .
above information is correct.I agree to comply wiih all Counry .
- ordinonces and Slate laws rela�ing to building construUion, _ . '
� and hereby aothorize repres.matives of this Coumy to enter � . �
upon th bove-me tioned ro ty for inspection p�r oses. SEE REVERSE fOR EXPLANATORY LANGUAGE
� �� �����
SignaWre APvlicani or A9ent Do�e . . . . � � . � . .. . . - . . . .
, , � , . . OWhER-BUILDER De
' ' ' � INSPECTOP.'S NOTES � CIARATION
i
�- � l hereby'affirm thar I ori�e empt from the Contracror's
�` "��'; '� �'� ^���" � � ' � -`' • �.L cenie Law for�the followi,c� reason (Secfion 70J1.5,
., -�-� - ' �� --'. . . ... .. . ... . ._'.. _.._.__... .. . _ . . _ _ _ .... __. . . , . - son r
, __. �., Susinei dFrofess'onsCode):Anycilyorcovntywhich
_ �', ' �� � . � ' - � �equires o permit to conslrucl,'oller,improve,demolish,
..�`�.• 5 ..�•.:.�� ;. ,..�.. '�.:..� .�.'�` �� -..' � . ' .. . � ,or repair any,sfru[ture.prlor fo�lls lssuancc; also rc-
. __" ,} \ - � - . _ .._ quires�fheappliconfiorsuchpermllJoflleas7gnvdsta�e-
j � � . � -. � ment fhaf he Is llcensed pursucn/fo ihe provlslons ol the
' . � � Conlratfori L7conse Low(Chapter 9(commendng wifh
.._ ._._ ._......_. _. .... ...,....._ . _._ _... .... . - . , Section 7000)of Divfs/on 3 0l fhe Business and Pro(es�
" . � . � '4ions�Code)or�hat he Is exempf�hcrefrom ond 1he 6asis
� � . � . � � � � , lor fhe olleg=d exempfion. Any violaf'ron o/ Section
�.. .' . . _ ._. . .. _. _.� . . �. . . . � � . . 7031.5 by any applicoN for a permif su6jects the oppli-
. . . . � . .. . � � - - ' - � , coN fo a Nvll panolfy o!nof more'fhan lrve hundred
. . .... . _ _.
��.__ _ __ . . __ _ . .. . � .
' . � . dollars(S500J.: �
' � � . � � -' \ �' �`- � � � � '� � ❑I,as owner of Ihe properry will do the work,and
' _ . . - . .. , . :� �he structure is not in�ended or offered for sole. -
^� - � . - � �. .'��. , , � . '� ' (Sec.7044,6usiness ond Prolesslons Code: 7he Conlrao-
� .. '. ' . _ � lor's Llcense Caw does not opply to on owner of property
'- - � � � � who bu(Ids o� fmprows thereon. and wbo does sucb
. � �� � � � . work hlmsel(provlded�baf such ImprovcmeNs ore no�
� - -• �� - �� - - � � inlended or offered for salm�ff,however,Ihe building or
� . . . � ' � � lmprovemenf Is sald wflhln one year ol mmpletlon,7hc
- ' � • �owncr-bulfdcr wfll havc fhc 6urden af proving that he did
� � - `-�1... �, 1 not 6otld or Improve 1or the purpose af svle.) �
. , ' - - � Q I,as owner of Ihe properly,om ezclusively,con-
� . � - 'Iroc�ing with licensed�controcfars 10 construc��he projec�
- �� � �; `. � � - -- � - -- � '(Sec.7044)Buslness ottd Professlons�Code:7he Contrac-
. . � � -for i Lfcense Low does nof apply fo cn owner of properfy
- � _ „ - � -- --� � - - - � . _ who 6Wfds or fmproves thereon,and who con�roc�s lor
� _ _ � _� � such proJec�s wifh a contraclor(s)licensed pursvant�o
� � . ' � !he Contra�lor's llcertse Law).
. � � � I am ezempt under Sec.
� B&P.C.�for this reason �
� . . : . . .. � .. � � . ' _
' .. i I , '. , i' Date
��- ' ,
._ ,. , , � � .. Owner
. _ ... . . - ._ .._ .. . . � . . ..
R�SPECTOR'S NOTES � �� � � � � ��- � �
_.. . > .. __ .i�- - - . _ .. . _ _ . _ . .
- _ �,y
, _. . . .. . .__ . . . _ .'ti ._ . ._. ____ . . __. . . ,
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_ ���..��-. .