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HomeMy WebLinkAbout0783A (4) i _ , � � WORKERS COMPENSATfONDECLARATION �� ' AP��ICA�I ION'FOR�TGRMIT �� '� j I hereby,o�fhm that t�have a certtficate ot coasent-lo aelf � - � . . j �nsu�� or a certrficate cf Workars'.Compensafion i�s�.a��e, HEAtiNG - VENTILATING - AIR CONDIiIONiNG ' ot a cb�Ifled topy thereof(Sec 9800,lab.C.) :� - . 7bnxaC. ,. .. . . _ . . � � , �/07/2: `Z' ~— c�.a�ai�v.io�e�� Pol ompany �C(k-'.:�"►^S �'?C GpUNTY OF LOS ANGElES - BUILDING AND SAfETY ��.��'"�Certif(ed�copy ia here6y.fumished. , . ;� �� � � �� ��� . `Q. Cenifed copy is filed w�th tbe county buililing inspec-. FOR APPLICANT TQ Flll IN suitDWG �g' � � �� i � lion depnrtment. ' ��1,� n� i .. �(PRINT OR TYPf ONLY) .. ADORESS . �Date��Appticant��^'�Y✓tQ�►r�l�.,Y{/r � . . LOCALITV iQ �„ . ' . �NO. TYPE QF APPl1ANCE ON EQUIPMENT��� FEE � -' '� � -CERTIFICATE OF EXEMPiION�FRQM WORKER5' �- . NEnRESi � � t :. . . .. .. COMPENSATION INSURANCE -'�" . �.. � �.� ... � -. CROSS 5T. �. I ABSORP�ION UNIT,BTU DISTRiCl NO. ' PROCESSEO BY �„{Th�s secfion need noT 6e wmpletad tF 1he woiic Involvad by � _ i 1he pe�mtf Ia ior one hundrod dotlars(Si00j or less.) � . AIR HANDtING UN�T,CFM�� .. � I q m� '. -�-I terfify,)hat in the performance�of.ihe work�for wbieh ihia . � SJ �� � �:permit Is Issued�,Y aKa�l not�employany erson in ony monner � � ' AVFROVAlS �� CATE � INSPEROR'SSIGNATURE �� � �eo as to fiecome eubject fo ihe Workers�Compenaption tpws. � BOILER,BN - � � � � . �. ' � Dale ��etpHcaM � � � fOMPRES50R.e7V� 1��`LQ� . . . .. V ROUGH� j � � NOi10E�TO APP41CANi:If,�after maki�g iMs�Certlficote of ���VENT1iP.jiON SYS7EM � � � . . F�NAL ��. � �� 'Exemption;��yov�should become suh(ect-to�Ihe�Workers'_ � . , . ' � �� Compansation provietons of the�Cvboc Code.you tnust forth- EVAPORATIVE COOLER - . � � � . VALIRA �F� � , f �with'comply with.such�proviaions or-Ihis�permN�thail be � � �, �I �� � deemed revoked. � � ' '� � �� ' �� . EUBNACE: fAU�GRAVIN � - � �. . . � ,. - 'tICENSED CONTRAC10R5 DECIARATION � FIOOR �� BTU O -� � . � � � � � " -� 1 her affirm Thot I dm liGemed under ovialoni cfCha ter 9 � � �SU$PEN6Ep - �UNR� ' � _ . � ' � �y D� . P . HEATER: WAt.. �. � ��(commencing wtth Sect(on:�7000�-oi�.Division 3.of the 8usinass , '� , � � and Professions Code,ond my iScensa is 4n full torce aod effect:� � � �� ' ���' � � . " . . �p '� , :_ �f�y��/ ,� /,,,.,� � - '� �J i ���tftense�Number `1./�,`!��Lic.Clossl�,LL,mLG_.. .. � . . ... , � � . � r o���l�l �ancanr 11s.�`�""� �-I'7--�r) _ , g � �❑ 1 om exempt uAder Sea - � . . � � . . � � - . `� ;. ; ,. Plan check fee s.8v.t.for�hia feason pERN11T f55UING FEE!� Q r'j � � , � - � Dare: � � . . .. . � ; TOTALfEE ' � SignaNre- . . . . . . � ..�. . .. . . . � i ' I hereb affirm t�NEam exeDmRt�framARATION�". , ... PIAN CHECK APPLICANT . .. . �� ��,�, . . . � ! i � Contractor a License . � � � . . , . �. . Law for 1he following reason(Section 7035.5,8usiness aqd NAME� . . � . � � � .- � � � . � � . � i ��, -Professlona Code): . . .• ' ...` ' . � . . . . . . , � � . � � � ' Q 1,es owner of�the propery, or my empfoyees�wiTh ADORESS ' ,.. � � . . � . . � - . �� � � - -���� �woges os 7heir sole compensatlon,.w�ll do the work and - pTY �-; -- ' TEt.NO. � � ' � � � ' � the strudvre is not imended or offered for sale�{Sectlan � � . � , , ��� � 7044,Busineu and Profeasions Code�.�. . . ..� .. .�. .. . . .�-. � -. .� �.....� .. . � �� �. - .. ..... . . . . � ' � � 6WNEk ,/� - . . ' '.. + ❑� I,�as owner of ihe propeny,am exclueively oonimctlng� - 7�Y� r . �� . with licensed conhactora to constru�f tha project(Seo-� p�ppRE55 � �n �,Q O �g y`4 �O 7�3� - �� -fion 7044,Business ond Pcofessions Code. � � , - CONSTRUCTIONLENDWGAGENC� --� � ��Ty �� �h�,� ` I hereby affirm Ihol there is a conehucfion lending qgency for --� � � � p- � � i the performance of ihe work fOr whith fhis perm{t is iss�ed CONTRAR4R-�` �. ��CP �� �� ► � . #����.�y � �, . {Sec.3097,Civ.C.). � . . .. . . � � . ._ ..y. . ..... __ . .... ... ��. . . . . . . � ._.... .ADDRE55. . ' � .. Y. ' . ,��.. .. _, . ... _.,_ ._,. _ _ '. "�,i..��:U�Cl'L�� ... . . f, lender's Name � � . i - � .� � .. . . . . . CIIY. .. _... . . TEL..h10.�a-�".0�7� _ ._.. .. . ___... . _,.._._. �.�{.,►Llb,PrJ2T3'..... . Lender's Addrosa � � � � � � - ' STAiE . � � f UC. .���. .� ' � ! � �i cenify ihai I have read this applicotion and staTe rha�tfie �..•. OCENSE�NO.�.. �—��7.C7 �-•ClAss. . .. . .-.-. . --.- ..-. - . .. .-Q.$j...'-F.+$,"/. � , ... _,. .. ._. . ...__. above information is correcl.�agree to compfy with oll Couny - .. � . . .. - � . . , ' � ordinances and Stote lows relating to�boildi�y constructiop, � � __, ,,,, , ,, ,,,;, � , _.,. . , „ . ,.. ,_ � and reby duthorize�epresentatives ot thia Coonty to eMer � � - � � ;�����- �� ��� � � ������ � ��� - � up e ab�m tis�+ oned p�rlapertgfor inspaction p`rposes. _.SEE REVERSE FOR EXPIANATORV LANGUAGE �'1 �.1� �� 9 7�87 _._ __ _ . _ _ . . �„ .� __ . .. _.. ; _�. � � _ _ _ , , ,� . ., .,.. .. . .. _.:. . �: , , .. ; , ,: , - � ,. "�a� . ... . . . ... . ... `x -.s.,. ,. , . . , . . '-': "' �C.''`,; >,r - - ">- - : �INSPECTOR'S NOTES "' , 4WNER^�UILDER DECLARAX�QN''`�,;. . �� . ,;.�;,, P�. .., �,... _. ... .,,- . ,...- .. ...•„., � � .�.. .,� -� . ..- --F-hareby�aff'irm-�ibat�l am exempf�from Ihe Contrrictori ,- �� ' "' � �"' License low for:ihe.�.following,rmason�(Secflad�7031.5, � .__.. ..._. _._ .....:. ... ._ ._.....�.. ...,. . _.:.., .__..... ..._...... B 1 d f 1 d 7 A 'i t � 1 h � �'""'��- '�" � us ness on Pro ess ons Co e ny a y or toun y , �. .�. . � .•, ���� �e ul�s o �mlt io const�cl,plfar,�fm rova,, � � . ...! _. �._ _ �._: ` _..� � �_;_;� �� ' .�.+;:. ',,.1 � . $,�,�. guir e opplfe ch perm�frto P a l'gde'mo ish. . , � o e o7 rvcture, or hsu nca, also re- _ �esth antforsu ilJe s nedstafe- � � � -���; ..._ � � '.:��� � �` Co'ni�aci�r�gticetnie'IawuCf�aR�a�ff(cammiencin�wNh ' 7 � P 8 . ".'"""'"... . .,"'"',..;'" .'..".'"""""``......""" ' " ` � _...�.__ _ ' .'���"- i � . ,. SecUon 1000)pi;Orvlslon�3 oi�he,8uslness and Proles- � r v .:.; ...._. ..-_-._f ...� . '".. . _. -..'" i ' ``i � ���}S 6�F��v�ot he)s exempt ihe efrqrr�ond�he 6asis , � _� ( - g d�ex p��on,A y �olaftan of SecHon '_ .:: L._. - ' Y PPAcanf ioc a permlt sublecfs the appb- ' ,,; i � �. „. pR q, penolty uf.not more}hon f ve,bupdred ; . _ .._ _ _ .. ._.. . ..._..- --._...- i a dollare�S5P0).� . ' � � � „., i. � � , , . . � I_._...._.._._ _ �� .. ��-' . - . ._�.. ..- - �.. ��. �.: ' ❑I,as Owner af,�fhe properfy wlll do fhe wotk,.and ._.. ... _.. . _ �..._ � . . ' i t ..�, . �,��, ; � .. f . ���.� � the�ii ucfyre.is�noi inTanded�or pfferad fpr�.sala.,. . '. •.__� �_ � . ��'. . � . . �,. . �..------- -�-= '�-..-- --. .. . . � - � s .,,.. (Sep.,7W4.�usfnessond}'rb/¢rslorisCod'e.� 7heCon{rao- . _ _ ._... . . _ .. . ___ . - - . � '� , ."{°.,.'�: . � � .. . ... . I ; aor;s.,f�/cense tow,does not,.pPP�Y.fo an own¢r o/property I. '� ' ` ' '�'"����� � c � � -" � �����,� ` ,� �;.who�bulids'or Impravea,)hereon,,and who�doaq:�such {. ..:4 _ _ .____ .._ __._ - -.- s . . , � ._, . _...,_ ,.'.- � �'j y work bimself provided Ihai such lmprovemenfs are nof ,. � . e; � _" Intendedor`olfered�fo��abie:l/.howe4er;lthebuildingor � . � ' ��,, .�..__.._.�,.,.. ._....__. ' ,„-�' � �• �:�-.;tmproremen���s_sold wlth�n one-,yaar of tompla}7on;�he � � � � .a__... { - -_... -r ---�-�: ,s'... _....-.... 4 ��''�owdet-6�ifder w�ll have fbe burden olproNng�hat.he d7d � , _ � . � � .. � . � ;�.. , ; �- �nal ffufJd Or improve for�Ae purpose titsole) `�'-'��� .�. , . , 1 : -'.�,: . : � , i , '. . . ,- _. . -. .-.. . .-t . �[7 I,as owner of the propery,am exclusively pon �, �� � � f fi �'� "���ratltng'wffh 1'tcens�d�tontrnctors to censf�uct ihe p�djed �.; . :..__ .''__ �.._.....__.. _..__--�� ' �. . . . .,. � - �- -��-���� �---- �--' + (Sac 764d)�uainess andProfeselons Code:;ihe�Contrac- I � � . � � � �' � �or'z LlcertseYawdoes not applq-to nn bwner of proparfy ! r_ " i I i . . __:-. ---_'_.__.__ .._.__.....__-'.... .._..,.___� ....._w_ho bqllds or lmproves�therean,pnd who contrqctd for � — ; , ' � � � � �'��' �i svch proJecls w!}h a mntracfor(a)1/censed pvrsuonl!o , . . _ r.�- __ _.. ... .._ ..._._._ . ...... _ ... . r.. . I .�. . . . • . , .- . -. . ..,. �. . —..�tiie-@ardrvctar'stfeenselew}. '`... , .__ . ... . -._..__...__.. ..._. . ._.__._....� ..,. , �. _ -._---._. ____ ._ �.____.......__... __....___ ! . �; ,"}�4." . . . . ._ . .'"_". . . .. . , ..."__... . _._ .. �. . , �. . _......__.. ... ...._...._ ._._. .__.. . . _ . , ,..� , f am ezertipivndaiY�t:�.'�s ,� . �,. . ., , �, . .. ��.�� ' ' ; ,. . . _- _. __. . _... . - .,. . . . ,:.;,., . . �,.:.... , ,_ . ..,�. ,..: �i � � . . .. � .. . ( . , .i.. .. ..,� .� �': ..� B&�P C.for this reason� .. i . . �� . . �._i �, . ;�� � .. ,,,� ,. ..,. ,., . � . ,:_�_. �, , q:�,,� � ..�.c:- _, � . . ._. .... .__ . . . .__. _ _... , .i. _ � , ' . ;. ` ,..,.• }_ � ' �. . . '1 .. , ..lz: � ' �____._. ._._._..._. _,...._..... .__. � . �� . , . ,. y . . - --"'..._.._.. �__._._.Y , ,� . . . . r � . . . � � ;..` . -:�� Date . ..-;. . ;,.. ., a _ ....t._c ._. .... �_ ._c:. ._._, ..,�r, ��-i - �.. ,.. �. -.,.. . . �.i �' . i � � � ; � � , „ .�.', �Owner` „�. _ � � � � r,:, ... . _s . , � �s�; �_ . .. __. _. _.. . _ .__ . _. _...._.___ _�._._ , � ,.. ,. ,.� , : . . � .. -� INSPECTOR'S NOTES _ __ : _ _ . . ----- r .,- . , ___ ._.._ _ ....__.. __, ,. _= _.__ � ____ _ _ _ __.._ _ _ ,.�� �, . _ . � .. � �. . ,,:i , �: . _` i. . . ..,,._........ ..._.....,�_.. .......».,,................._.... ,..,_........._. Y�, . .:... . sr.. .....,.� . :�... .•.c... ' �� ..... ' .-�::�,� .. ., . , .� � '„ ...-. . ...� ., . I ,�_ ..� .. .a�._„�.. .. .� , .:.r. . - � . f . Y4 � . ..._.. . . � \