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Home My WebLink About5652A (17)I WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby cffWm that I have a certificate of consent to self intwe, or a tertificate of Workers' Compensation Insurance,'HEATING VENTILATING - AIR CONDITIONING or a certified Copy thereof (Sec'- 3800, Lot, .) 76A364C CE Big long �� <ZX/ - (REV. PPCkyN499Qzz-:1C_-mPor`Y COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished. OWNER -BUILDER DECLARATION PLAN CHECK APPLICANT Certified copy Is filed with the county building In3pec- FOR APPLICANT TO FILL IN - BUILDING tiondepartment. (PRINT OR TYPE ONLY) ADDRESS D Applicant NAME LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEARES S COMPENSATION INSURANCE CROSS . (This n need not be completed 1f the work Involved by ABSORPTION UNIT, BTU msm,CT No, - ROCENED By swill one hvil ($100) or less.) permit far d of,. CITY TEL. NO, I In I certify tha the Performance of the work for which this - - AIR HANDLING UNIT, CFM 10 %P& permit Is Issued, I shall not employ any person in any manner BT, I I,o,owner r sous to become subject to Workers Compensation Laws. --BOILER, APPROVALS DATE INS" lays Dole Applicant COMPRESSOR, BTU ROUGH NOTICE TO APPLICANT: if, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to 'the Workers* hereby affirm that there is a construction lending agency for :h N�. Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit sholf be CONTRACTOR Z11P4 A/' deemed revoiked, FURNACE: - FAU GRAVITY .7 LICENSED 'CONTRACTORS DECLARATION FLOOR —BTU 1 hereby affirm thatiom licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT '(Commencing with Section 7DO0) of Divisicm�3 of the Business WALL TEL and Professions Code, and my license is in full farm and effect. lender's Lender's Address &VzA&,& 0, M�J ------ .. ----- I certify that I this application and state that the ' license Number 'LIC, Class LIC _ _r ASS i or of n is orrect. I agree to comply with above 1 m e ordino s a Slat lows relating to building construction, m am exempt under Sec. Plan check fee and he e y a I, ori,E representatives of this County to enter p se SIGNATURE AP.C. for this reason —Date;— PERMIT ISSUING:FEE 7777D*A11. FEE Signatur OWNER -BUILDER DECLARATION PLAN CHECK APPLICANT ;F 5 6S 2 A I hereby affirm that I am exempt from the Contractor's License Low for the following reason (Section, 7031.5, Business and NAME pop. # - 8 Professions Code): ❑ 1, as owner of the property, or my employees with ADDRESS 30, go wages as their sole compensation, will do the work and the structure is not Intended or offered for sole (Section CITY TEL. NO, 9 i. 1, 3 0 5 0 5 7044, Business and Professions Code). I,o,owner OWNER 10 9. 1 1 8 4 of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL ADDRESS tion 70", Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY EL. hereby affirm that there is a construction lending agency for :h N�. performance of the work for which this permit is Issued CONTRACTOR Z11P4 A/' (Sec. 3097, Cly. C.). elUe- Lender's Name CITY TEL lender's Lender's Address &VzA&,& 0, ------ .. ----- I certify that I this application and state that the ' L'ITCAETNSl NO. / /3,5_ 7, '32 LIC _ _r ASS i or of n is orrect. I agree to comply with above 1 m e ordino s a Slat lows relating to building construction, m and he e y a I, ori,E representatives of this County to enter p se kh,ead upo boned properly far Inspection "a SEE REVERSE FOR EXPLANAT06 LANGUAGE 19nor— A.t Do,. S' licomf ..t tNSr CTOR' OTES ON€R 11Ui 6�'ER DEC LARATION �. �. ate fr �m'aha Cont� ' t`fie'�Rrn-that eby i om'exempract LicenseLaw for the following anon' (Section Business and Professions CFode) Any city orDunt wh¢MS _ 'req uires fo alter, de Air _._or o pe)fift consltuct ,improve, any to If. fssuoncp, re. � 'r �" % 7 repair sfructure, prior ;afro I .-.. - quires fha applicant for such permit to frte a sfgaed sfote, .._ _ .. r , C� of that Is licensed pursuant fo fhe provisions of the Co Ucens Low(Chopta 9(commendng lth ' Contractor'ss l _. ",' ' • t ; - ✓„ , •µ f, - - Section ' ihe f 1 is rk fhiher6from, and the basis s an, ode00or tf ofexs i fleged exempAnyioioffon of Section or the ation yp3f $ by any 8ppi¢onr fora permit sublets the apple- .:;cant to a civil. penalty. of not more than five hundred - dollars $500).: i - I -`----- ___-_ _ "" •"'�`' C I, as owner of the property will do the work, and st ciuieig:not mlendeii or q(fered;for sole._ i A' �$ec. 7044, Business and Professions Code:`, The {orjtrac- -rtor's iticense Law does not apply lc an owner of property --'"-----'"-<who builds or,lmproves. fhereon,,and whodoes. such work himself provided that such Improvements: are not - I ' _ ... _.. ., _ ' : intended oc'dffered for safe. if, however, the building or -Improvement issold within one.year of: compietton,, the - ` `'� ', • -.-ownet-builder will have the burden of proving that he did not build or Improve ftir the purpose of saki)," t ` wnerOf am exclusively con- .:❑wd6sl ensed'controctars t'o; construct fhe project ' • ---- - - -- - - --- - - - - - -- (Sec. 7044) 86slnbss;cod Profgc onj Cale The C-1-41; License Ldw does nat eppfy tb on'o."i? df pkop6"y who builds or Improves thereon, and who contracts for -such projects with a contractor(s) licensed,pursuant'to the Confractor's License Low)-. f am exempt undef Set: - - 8-& P.C. for this reason Or,0;4:V Date l -77 ti 1NSPECTOR'SNOTES- aif � �-