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WORKERS'COMPENSATION DECLARATION APPLICATION ����� �
I hereby affirm that I have a ceriificate of consen�to s�f � � ���
insure,or a tertifimte of Workers'Compensarion In � anseac HEATING - VENTILATING
or a cerlified copy thereo)f(Sec.3800,Lob.C.) �.g18(REV.10/81) �
Poli[y NoLULfOpL�*+IGtampany , . . . � .
❑ CerYfled copy is hereby fur�ished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed with the coumy 6o�(din9 inspeo- FOR APPLICANT TO Flll IN euuowc '
Dafe�ti0n d pa finenL . ` . (PRIM OR TYPE ONLV) ADDRE55 �+�� /_
Appli[aM���_ NO. TYFE OF A7Vl1ANCE DR EQUIFMENT FFE LOCAIR `
CERTIFICATE OF EXEMPTION FROM WORKERS' NEnRESt
� COMPENSATION INSURANCE CRO55 ST.
(Tht�soct�on no�d nol ba complNod t(the work tnvolved by A850RPTION UNIT,BiU OISiRi[T NO. . - PRO �BY
Iha psnnit la for one hundr�d dollan{f100)or lens.� qIR HANDIING UNIT,CFM
I certify that in�he performance oi the work tor which this � � .s:—
permit is issued,I shail not employ any person in ony manner BOiLER,BTU
so as to becOme svbjetl to Ihe Workers'Campentatian Lows. ��f araaovnis DATE INSPECTOR'S SIGNAiURE .
Oate aPP�i�a�� COMPRESSOR,BTU To IlJ - - - IO O� ROUGH
NOTICE TO APPLICANT: If, afier moking this Cenificaie of yENTIIATION SYSTEM � fINAI
Exempiion, yo� should become subject to Ihe Workeri
Compensalion provisions of the Labor Code,you must forth- EVAPORAAVE COOLER - V/�LIDATI�1�
wl�h comply wifh such provisions or this permit shpll be
deemed revoked. - . � FURNACE: �FAU_GRAVITY - �
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm Ihai 1 om licensed under provisions oi Chap�er9 HEAiEk: SUSPEN�EO UNIT_ .
'(commencing with Section 7000)of Division 3 of the Business ' WA« � �
and Professions Code,and my license is in full force and effoct. - -�� >'
a
O
License Number�X�A� Lie Class� � � � �J '
Commctc�r.�'r�,t� �+yL-^•�te__��:��� �1 3 0.D A �
� . . . �
1 am exempt under Set. � #� �$ w
Plan check fee, a
. B.BP.C.for Ihis reason � • •2 Q Jr� 'n
pa e, PERMIT ISSUING FEE S /O U � � � = z
TOTAL FEE •2 0.5 D c.,
Signature � �
OWNER�BUILDER DECLARATION PLAN CHECK APPLICANT �2 2 2-8 CS
I hereby affirm that I om ezempt from the Contwctor's License � - �/,(� �
Low for Ihe following reason(Seu�on 7031.5,Buslness and NAME . � v-'�
Professions Code): � � � , �
� ❑ I, as owner of the p�operty, or my employees with ADDRE55
wages as their sole compensation,will do ihe work and � . �
the structure is not inlended or offered for sale(Seclion CITY TFL.NO.
7044,Business and Professions Code). . � �
OWNER f
❑ I,as owner of Ihe property,om exdusively[ontracling � �` . - . '
with licensed coMmcbrs to construtl the project(Seo- qpORE55 � �
� ' tion 7044,Business and Professions CodeJ. .
CONSTRUCTION LENDING AGENCY CITV TE�.NQ � �
I hereby affirm fhat�here is a construction lending agenty for ,
the performance of fhe work for whith this permit{s issued CONTRACTO � � -
- (Sec.3097.Civ.C.). ' � . .. . . - .
nooeess�/ !/ � !p.: u _
Lender's Name .
CITY �� ��� . TEL NO.s �y . . . ..
Lender's Address - �
STAlE UG.
1 cerlify Ihat I have read this application ond slate thol fhe LICENSE NO. � C1A55 � - . . _.
above informotion is correct.I agree lo mmply wilh oll Couny '
ordinantes and State laws relating to building construction, _
and he y ut rize repre entolives of this Couny to emer � � � � � � � � �
o a ove e Y ne propeny tor insp iio pwposes. _ SEE RfVERSE FOR EXPLANATORY LANGUAGE . .. . . .
re of ppliconl or Agenr Date -. . � . . . - . . . . . ..
F�o.�' 'R i F4.=" ' . . _ . _. .. . .. _ . __ . .._ . _ . .
���� ���`����� ' 4 ; • , INl�ECTOR'S NO7E5 - , OWNER-GUILDER DECLARATION ,
�
, - -�� I iie"reEy 6ffi.m��hot�am e �mpt'froin 1he Conrroctor's
'' , � ' � "'" �' � License Low for th= following reason (Sec�ion 7031.5.
-..V_.�_..... .. . ..__.._...._._..... ..... . ..... . ...".. _ .._ _ _. .- __.,..
� ' -'�-"� '' " "�"�� " � '" "' Business and Prolessions Code):Any ci�y orcounty whlch
, i ' .��1 ��--�� - � requi�es a permn lo consl�ur.l,olter,lmprove,demolish,
- � � - � �� '� � - - � � � � or ropcir ony strucfure. prior�fo i/s�issqance, olso re�
�. . ��� . j , �-.�•qui�es fhe vppli�ont for such permi!fo•file o digned sfote�
, � -�� ` - -�`�� � ' � menf/Aof he 7s fitensed pursuanf to fhr provlslons 61 fhe
� ` Confraclor's Licrnse Lew(Chapfer 9(commencin�j wifh
'_... ..-.. .__..... ._ .... .. _- : . _. � . . � . . . . � � Secfion 7000)o/Divis7on 3 of�h�c Qusiness and Protes-
� ` - ; � � � sions CodeJ or�hal he is'exemp�iherelrom on�}fie basls
� '.. _. � ; . .- � "�� �or Ihe 'alleged exemptlon. Any vialction ol Sect�on
, _..... . �. .. ,.. . . , �
� . . . _ .__. ._'. _.� _.___ .". _ � : , 7031.5 by ony cppficoN for a permil svbjects fhc appli-
, . . --- -- � ' cant fv a civil penolty of no�more than (ive hundred
. _ _ .__.____. .. _ .. .. . . d rs550 �
• ol(o ( 0�.:
� I i � ':' -�\`�� _ -. - - �'��\� � � ' . ❑I,os owner of�he properiy will da ihe work,and
� � � . � , , . . - the struuure is no�iniendeti cr offcred for sale.
'- �--�----- --�- - - -� - - - ��- - � � (Soc.7044,Business ond prolcssionz Codc: ihc CoNroc�
� � - , . tor's Llcrnsr!aw docs no�oppfy fo an owner o(properly
� � - � who 6uifds or Improves Ibereon,.ond who does sucb
� � �. . _ _ . _ . work hlmsell provided thof such(mprovemenls are no�
, ' - - infcnded or olfcred la,-sale If,howcvrr,the buddin9 or �
�, - _. , . , improvemenl!s sold wi�hin one yoa�o(complefton,�Ihe
. � - � ownenbuilder wlf!hcve Ihe burden ot proving Ihof Ao did �
. , no�6uild or Improve for Ihe purpase ol sole.) �
� , - � - � - - �3�1,os owncr oi ihc,prop��iy,am cxduslvely con-
. r . , . YraCling wilh licensed contractErs�o constrocrihe projecr
- - (Soc 7044)Buslrress andPcolossions Co�lc�,7hc Cort�roo-
y. � ,. � o ' " ' �t�or's�t�censeLowdoes'ndfappfy'fe�anewher'olproperly
' � " � '- --- -- �� -- ' who bulfds or lmproves fficreon,and who confroch for
� .. . 4 _ - �� � � svch proJecls wifb a controclor(s)ficensed pu�suonl fo
. - the Confrccfori license LowJ.- � - �
� - � _ , ���. - -
_ • • j . . _ . '. . . _ . ._
;��.
,' _.- ,C,:: � , - . ___ �. _ . .. . . _ . . . .
' � � I am exemp��nder Sec." �
I � B&P.C.for�his reason I
- -- — --- � - _ - � , , Date "
. , -- . -'�..� � . , ♦. �.K,r.-�<,� .. ' Owner � . . - .
. - . ;�
__ _ __. _._...- - .-- .. 1.._,_; .,�
`' _, . ...... ._.,1-".�
INSPECTOR'S NOTES ���- - -��"�" �� -�� � ' �
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