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HomeMy WebLinkAbout1322A WORKERS'COMPENSATIONDECLARATION APPLICATION �FOR PERMIT � � I hereby affirm that I have a certificale of consent to self �-�j � insore,or a cerfifimte of Workers'co �5oro�i�5 ronce, -76A�"� �HEATING -�VENTILATING - AIR CONDITIONING or a certified a Sec.3800, a .C. Y `J� CE•BIB(REV.10/el) Policy No. pa^r "/� � COUNTY OF LOS ANGELES BUILDING AND SAFETY� � Certified copy is hereby furnishe . r�J /!/ Certified copy�s f�led wuh the coumy bu�lding�nsp - FOR APPLICANT TO FILL IN euuoiN tian departm AODRES I (PRINT OR TVPE ONLY) � Data'��Plicant IOCAUiv NO. NPE OF APP�IANCE OR EOUIPMENT FEE CERTIFICATE OF EXEMPTION FR WORKERS' NEnaEST � COMPENSATION INSURANCE � CROSS 57. (Thls saction naad not ho compl�hd if 1ha work Involwd 6y ABSORPTION UNIT,BTU oisrRicr No. ra [sse�ev I TM p�rmif 1�for on�hundr�d dollars(f100}or Iass.J qIR HANDLING UNIT,CFM — / � I tertify lhat in the periormance of the work for which this p-• permit is iss�ed,I shpll nol empioy any person in any manner � gpILER,BTU so as to 6ecome subject to the Workers'Compen5afion Lows. AreeOVnlS DAiE INSFECTOR"5$IGNAiURE Date ApP�iwnf � � COMPRESSOR,BTU ROUGH � fy NOTICE TO APPLICANT: If, affer making ihis Cerfifimfe of VENTIIATION SVSTEM FINAL . �L��. �Exemption, yoo should betome subject to Ihe Workers' ,� . Compensation provisions of the Labor Code,you must forth- EVA7pRATIVE COOLER VALIDATION with comply wilh such provisions o� this permit sholl be . deemed revoked. � FURNACE: FAU GR � UCENSED CONTRACTORS�ECLARATION . FIOOR . I hereby aifirm ihm I om licensed under provisions of Chop�er 9 SUSFEN�ED UNIT_ - '(tommenting with Seclion 7000)af�ivision 3 of the Business HEATER: w � , ond Professions Code a d my � nse i ' full force nd effecl. >" a license Number / ic.Cla s — - ► � V � a Conlracf . - 1� �2,�,4, � ❑ I om exempt�nder Sec. � � � W Plan check fee �° 'B a N B.BP.C.for ihis reasorc PERMIT ISSUING FEE S z Dafe: Sgnotore TOTAL FEE � • °��7 5 - OWNER-BUILDER DECLARATION PIAN CHECK APPLIGANT , • • •S`I�]�c�., I hereby affirm thot I am exempt from the Contractar's License , , ' Law for the fol�owing reason(Section 7031.5,B�siness and NMnE I 2.0 9—b 5 Professions Code): ❑ -I, as owner of the property, or my employees wifh ADDRESS . . wages os iheir sole compensation,will do the work and ��,i Ihe slructure is not intended or offered for sale(Section CITY 7EL.NO. 7044,Business and Professions Code). OWNER ❑ I,as owner of the property,am exclusively contrac�ing with licensed contractors to consiruct Ihe project(Sec• N''41L � � tion 7044,Bvsinezs and Pra(essions Code). NDDRE55 �/� CONSTRUCiION LENDING AGENCV . ��T � . I hereby offirm that there is a construction lending agency for — the periormance of the work for which this permit is iswed CONTRAR � , (Sec.3097.Civ.C.). . . _ ... . . . ADORE55 . . . .. . . . _ Lender's Name Lender's Address � � � � - I certif �hat I have read thrs a I�mtion and sta�e that�he t TE Lic. ' , � y pp LICENSE NO. C1A55 . . . . _ , o6ove information is correct.I agree lo comply with all County ordinances and Stme laws relaring to building conshoUion, and hereby aufhorize repr enlatives of this Counly to en�er - �. � - � � " - � � � � �t, ar bove-m t' ne �pe'rt/y yfo�r inspgc�_rpos SEE REVERSE FOR EXPLANATORY LANGUAGE C.c�/L% r>� - Signature of Appl�cani or Ageni Do�e . . . .. .. ... . . .. . . ". ' . . . . .. � ,.. . . . . . . - . �.� � ., i. . . I�. . , * � ' • � INSrEcro�'S►aoTes , OWNER-BUILDER DECLAP,ATION � --• �� � - -� ,�1��croby affirm�ho�I��am �pt from the ControUor's � � . � �- - �' � '� �' ��� � - � . ��,-License,�Law�far the 4ollowing rcason (Setfion 703i.5, .- . . ._'�.;..�..: . ..; .____._ . . ..._ .. """ '.' '_ __,__ ... . ..- "__..... ' _. . .. .. . . sions Code):Any city or covnty whlcb , , . '�Buslnoss and Froles � � '�� � . ;� ' � . � �requlres a permlf�lo consfrud,alter,improve,demolish. � � '� - ��� -� -� � � � � `oC�repalr any�siru[fure, pNoY�fo!fs issuance, vho re- j --- ,, �ti', \ '. � ' - � . � .'�qoires/heopp�icdnfforsuchpermil�ofileasignedstale- . � menf Ihol he Is licensod pursuanf}o fhe provislons of/he � - Canfrodor's Litense Law(Choptcr 9(commendng wifh '.._..__....._ .__ ..... . . .... ......._.... . .. � . , � i . , . _ SecNon 7000)ol Dlvision 9 of Ibe 6�siness and Proles- � .. , . �slons Code)or fhal he is�esempl Ihe�elrom and}he basis ; . ' . -. . . � � � ior fhe alleged exempfion. Any violafion of Secfion ' � � � J031.5 by any applicani(or a permit subjecfs 1he appli- . ... .�. _.. - --- � - ---- ---.. . . .. . . , . .. . . , -. . . � �cont fo a civil penally.oF nof more than five hundred .__. ._ ._.__.._ . __.. . ._ . ... .. . . _...',`, - � .. . . . . � � dolfars(5500).: � � '' ' ' � ' - �' � � � � []I,as owner of the properry will do Ihe work,and ' � . , .� . -.�• . . _. __._. __' � . ... .. . _ .: . : .. . , _ . , , , � `ihe siruclure-is not inlended or ofEcred for salo... ' i--�._._.- .-.--' ' -r._.�. ._. �� . ._... . .. . . .; �' � �, (Sec70a4,BuslnessondProfessionsCodc: TheConhor � ' - , ' � . ,, for's Lkense Law does nof apply fo on owner ol property � � � - -� . ,.who b�ilds or Improves fhereon, ond who does:such . . . _ , work hfmzell proNded�hat such�mprovements arc not • � '�.�"' ��`�� -� ' � �� \ iNended or oflcred(or safo.1(,however,1he bulfding or � ,. . . .. . - ��Improvrmenf Is sold wUhin one year o(completion.thc ' ' -- � �ownervbui(derwillhavelhebordenolprovingfhvlhedid ' , �, . - . � ; �� � , not 6utld orlmprove for fhe purPme of sofe.) � ' . . 1 . �� �, • � ❑I,as owner�of thc propery,am exdvsivdy con- . � � - �Irocring wirh licens=d contraUors�to construcr thc projec+ . „ � - � - - - _ (Sea704A)8uslnesi�and P�olpssionstoder The Conlroc- _ ' ' � � �. �. - � ' ior's L7cense Law does noYapply to an'owncr of property , � � � - �� � � -- - who bullds or Improves fbereon,and who contracfs lor ' � � � suth p�ojecfs wilh a confracfor(sl licensed pursuont fo :�,. ':. . �. ... . . . . . . . .. - . �--- fFe Contracror's License Law,1. .. . i ' , _ . . . .._ . .. _ . ' . - . � , � � I am exempt�under Sec. � � � � 8&P.C.for fhis reason - �� ' � , . , � Date � .,Y� , . `� , , _ ,Owner \ . _ - . � .'.. . �._ ' � ' . . ..- ..,- �i� -.' 1 (� .�•�, \ � _. , .. � � � INSPECTOR'S NOTES ' � � : , _ . . . � .. . _.. . . . . _ .. � ' '� � . --- . . ._ - - - --- . . .. '.\. . � _ -.. . �� .. . � . . . � � _. . � , , .. . .� . _ ... ._. . _-._. ... _.— . . . . � � . . . . � . . . � , ._ . .. .. _. .. . . _ . .... . . . , , . s . . . . :�._ . ' . \- • . _ .. .. _ , �.\ ..