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HomeMy WebLinkAbout1131A WORKERS'COMPENSATIONDECLARATION APP�,'CATION -FOR PERMIT � 1 here6y affirm thal I have a cerfificote of consent to self insure,or a certificme of Workers'Compensa�ion Insurance, �an36aC HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof(Sec.38�b.� �N^ - CE-8�8(uEV.i0iet) � � - � � � # POollcy No.f�$.�lST�n Company�F �i %1Q (�O Cert�fied copy is hereby furnished. COUNTY OP LOS ANGELE$ Ga1. y37 BUILDING AND SAFETY ����� � Certified copy is filed with ihe tounry building inspec- POR APPLICANT TO FILL IN BU�tD�NG � tion deparcfinen7. (PRIM OR TVPE ONLY) A��RESS � Dafe-���ra7 �Applicant LOCALIN d� {� NO. TYPE OF APPLIANCE OR EQUIPMENT � FEE �' � CERTIFICATE OF EXEMPTION OM WORKERS' - NeaeESi -� COMPENSATION I URANCE � � CROSS Si. � � (Thi�t�ctlo�n��d not bo compl�f�d I(1h�work involvad hy Ag50RPTION UNIT,BTU p151Ri�i NO. YRIXESSED BY � 1h�pormit is for ono hundnd dollars(5100)of lelt.) pIR HANDLING UNIT,CFM � �-y� ��• I ceriify�hat in the performance of the work for which this permit is issued,I sholl not employ ony person in ony manner ' so as io become s�bjeU to ihe Workers'Compensafion Laws. bOiIER,BTU qPPROVAIi ,DAiE INSPEGiOR'S SIGNATURE - � COMPRESSOR,BTU 2tp�«� � ROUGH Dpfe opplicpN NOTICE TO APPLICANT: If, affer making thii Cerlifitafe of VENTILATION SVSTEM . FINAI � Exempfion, you should become subjecl to the Workers' Compensarlon provrsions of the Labor Code,you mv5f forlM- EVAPORAiIVE COOLER VALIDATION wifh comply with such provisions or fhis permit shall be deemed revoked. . FURNACE: FAU GRAy V - � LICENSED CONTRACTORS DECLARATION FLOOR BTU C)Q � I here6y affirm that I am licensed under provisions of Chapter 9 SUSFEN�ED UNIT_ HEATER: WA�� . �(commencing with Settion 7000)oi�ivision 3 of the Business and Professions Code,and my license is in full force and effecf. � - r S� 5 " License Number ����G9 Lia Class G� - � � u eo�o-o��o��di�FcJF_s i oa�e��—�7 :'1 1 3 1 A o � t.• : • •8 v I am exempt under Sec. W B.BP.C.for this reason� Plan check fee I • •U 6 Z 5 Z pa e. - PERMIT ISSUING FEE S Jp g� . .'.4 6 2 5� Signat�re TOTAL FEE G80�-87 � � OWNER-BUILDER DECLARATION . PtnN CHECK AavtICANT I hereby affirm thot I am exempf from the ContraUor's License , . law for fhe following reason(Seclion 7031.5,Business and NMAE . Professions Code�: . ❑ I, os owner of fhe properfy, or my employees with ADDRESS wagez os their sole wmpensa�ion,will do the work and � � the strucrure is not intended or ofiered for sale(Section CITY TEt.NO. . 7044,Bosiness and Profess�ons Code). - � . � OWNER ❑ I,as owner of the property,am excl�sively contraUin9 � with�icensed contrptlors fo consiruct Ihe project(Sec- MA�� - � � � tion 7044,Business and Professions Code). ADDRE55 CONSTRUCTION LENDING AGENCY � � � . I hereby affirm that there is a consiruction lending agency for ��TVNew OIt BedCh Cd 926r���" 714 833-36 ; the periormance of�he wo�k for which this permit is issoed CON7eaCTOR IrvineS�est�EIt & AiI' � (Sec.3097,Civ.C.). . g . ., . _ . ADORE55 638 Southern Ave. � � � � ' � � Lender's Nome orv Orange Ca 92665 TEL.NO.('J1Q) 921-08 0 Lender's Address � . " I cerGfy Ihat I have read this applfmtion and sto�e that ihe. UCENSE NO. 46�i609 �ASS c-20 a6ove informotion is correct.I agree to camply wifh all County ordinonces and State lows reloting to building cons�ruction, and hereby authorize represenlatives of this County to enter ' �- . � � - - � � �`i��% n the above•m/entioned property for inspection porposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 9��f+--�- ! i�fe O I . . . . � � - . ture oF Appli�ont or Agent �Date - - ' ' - '- . ,..,,,.,; ; .. _ . • • � � � IN�PECrOP.'S NOTes OWNER-EiUILDER DECLARATION '-- • - ��';�t ������' -•��\'�7�ereb tif�irrm�that 1 om exem�t�from�Ihe CoNroctor's �. , .. ., .�,..�.. Y _ \\ �.�.��. .. . . .. :� _. •,...���..i Licensa law for Ihe following reasan (Section 7031.5. \.�C�- �` ` -.. .� ..... ......._ . _.._.. .. � . . . . .,_ ... .. .._. ... . . ... _ _ _.. ._. ....,. Business and Professions CodeJ:Any c'ly or<ounfy,which ' �� ��..=�, � . r . . ' �' � � �- ! �requtres a permll ro cons�roU,afier,�imp-ove.�dem'olish, ,,� " -� \ ' ` �� - '.:� �' • - . .. . ' ' � ' •�br[cpqlr any itructurc, prlor fo Its Issoance, olso re- ' ' ~ � �1 � � - /' ' � � ". ufresYhea Ic rV/orsuch ermttlolJeos edstafe- � - ` .�.'�l\�_i,�\ � . �---�� ., 4 � . PP'� P f 1S^ �-� . ���� -�- } - -' ' ' ' '� - - � � �, � menf Ihof he is hcensedpurs�ont}o Iheprovisions of 1he . � . Conlrocfor's Lkense Low�Chopfer 9(commencing wBh �� �� � �� ��"�����- ������� `�-� -� �� � ` � � .._ � � � � � , Settion 7000J ot Divis�on 3 0(1he 6usfness pnd.Profas- � ' � �� , sions CoJe)or fhaf he is�exempl there(rom and 1he bosls � � ' � � . . . � , , (or �he olleged eze�mplion. Any viol6lion o/ Secfion ,._ . � � � � �. 70?I.5 6y ony oppiicanf for o permit svbjecfs Ihe oppll- . _._..... ... . .. . .. . � . ' , . . . . � �. � --- � - � � ,.can�to o civi!penolty of,nbl morc fhvn livc hundred '- . . . .-.. .----- -- -- dollors(5500).: - , . - ��'� �� ' � ' "�' � '� � � `� ❑I,as owner of.thc property will do ihe work,and . ... � � � - � � . "-��ihc i�rucfure is not intended o�offcred for sole. ------- � -- — --- - � �- - - - - - -- � � � (Sec.7044,8usinessqndProlezsionsCode: iheConlroo- . . � � . . . , ' . �.,•for's Ucense Lcw does not apply lo an owncr ol properfy • � � ond who.does such � - � � - :,who 6uffds or Jmproves therean, , ' _ _ , � work hlmseH provided that surh Improvemenfs are no� ' ��%L'��-=`. �-'�'• � infended or o(lered Ior:afe.If,howevcr,Ihe 6Wlding or . � , .. _ _ . � . � , improvemenf Is sold wflhln one yevr ol completfon;thc ' ' -� � � � - � ovmer-bvlldcr wil(have fhc burden o1 proving Ifiol he did � � ,��,-`�1 .�.•;•,,, ,{, �`,, , ;, not 6olld or fmprove for}ho purposo of solc.J�� �. _. � .. ' � - - � -.t.,'�,�I,os own�F of,l!ip p?pperty,om exclusivcly con- - . - , �� . � � • �-- trading wifh licensed contractors to construct tfie projecr - � ' . - ' QSec,7Q14j BusMess and,Pro(esilons Code:7he Con�roc- , . - '. . , �•-l�.��o�'s Llcense Low doei ho�'appl}�t�o dn�oir%ner o/property - � - -- - - wfio butlds or Improves�hereon,and who contr6:ti!or� � - � � � ' - ' � � - � � such projetfs wl�h a conlracror(s)licensed pursuanf fo thc Confrocfor's!i[ensc Law).� ' � . , �. ;1 . . _ . . .._. .._. . . . . ... _ . . .__ � � ' � � � I am ekempl under Sec. �� . � � 8 8 P.C,for�his recson � � � � - -- --- - ----". - .- . . - - �� � Dote - - '� . i.. � . . . . , � .._ . _. .. ,__.�. . ._._�� � .. .. .. �. .. . �..Owner � � . . . .. . .... . . ' ' . . __.� . .: , � INSPECTOR'S NOTES � -- - � � � - - � .. � . � , l � . . . - . . � .`� �'- . . t.. ;�..� �� _. . __� \�- ... -� .