HomeMy WebLinkAbout1411A (7) • WORKERS'COMPENSATION DECIARAT10N � APPLICATION FOR PERMIT ' �
I hr�eby�affi�m tha� I have a certifitale of tonsent to self
insure,or a certificaie oi Workers'Compensaiion Insurance, HEATING - VENTILATING - AIR CONDITIONING .
or a certified copy thereof(Sec.3800,Lob.C.) 7CA36aC . .
ce-aie�aev.iorei�
P❑ol'icy No. Company �
Certified copy is hereby fo.nished. COUNTY OF LOS ANGElES BUILDING AND SAFETY e��, ���
� ,Certified topy ts filed with Ihe counly 6uilding inspec- FOR APPLICANT TO FILL IN BUILDING /
tion department. - (PRtNT OR TYPE ONIYj ADDRE55 /f ' Q
Dale Applicant L�'L�TM • l�1bBNZ7 �/J'�
NO. TYGE OF AFPLIANCE OR EOUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEaREST �
COMPENSATION WSURANCE CRO55 ST. '. �
(This sacfion nead not 6o complalod if the work Involved by� ABSORPTION UNIT,BTU OISIRiCI N�. PROCESSED BV
tha parmlf fs for one h�ndr�d dollarz(5700)or letf.) qIR HANDIING UNIT,CFM / �
I certify lhat in the performance of ihe work for which this j� n- �
permil is issued,I sho�l no1 employ any per in ony manner BOILER,BTU J � �"'(� �
so os to become subject to th orkeri C SaliOrl LOWS. AGiPOVALS DA7E INS CTOR'S$IGNATURE
Date — �� pplicant COMPRESSOR.BTU ROUGH '
NOTICE TO APPLICANT: If, o thi e oi VENTiL4710N SYSTEM FINAI ��
Exemp�ion, yoo should 6ecome subject to �he Workeri � '
Compensotion provisions of the la6ar Code,yoo must forih- EVAPORATIVE COOIER � AL ATIO
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU_GRAVITY � �
IICENSED CONTRACTORS DECLARATION fIOOR B7U
I hereby offirm ihat 1 am licensed under provisions of Chaprer 9 HEATER: SUSPENDED UNiT_ �
. �(commencing with Section 7000)of Division 3 of the Bovness ' �'�'A«
and Professions Code,and my license is in full force ond effect- � . y
C , V
License Number � �� Lia Class � � "
/�� / O/ �
ContraUor •� Date . O
❑ �141.1A �
I am exempt under Sec. W '
Plan check fee �.'. . .g Q- '
B.BP.C.for�his reason� � � �
PERMIT ISSUING FEE S �
U l;• •3Q50
Date: -
S�gnarure TOTAL FEE d • • •3 Q 5 0�
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT �� O 7� H�8 S
I hereby affirm lhat I am exempt from ihe Contractor's Litense '
Law for the following reason(Setlion 7031.5, Business and NAME T
Professions Code): �
❑ I, as owner oi fhe property, or my employees with
AODRESS r—� �
wages as iheir sole compensolion,will do ihe work and CITY � TEL.NO. �
the svucrure is not iMended or offered for sole(Secrion
7044,Business and Professions Code). �
OWNER •
❑ I,os owner of the properry,am endusively comraciing MAII �
with licensed mntractors to tonstruct the projen(Seo- qDDRESS Q �'�4'°'� '
tion 7044,Bosiness and Pwfessions CodeJ.
CONSTRUCTION LENDING AGENCY CITY TEt.NO.
I hereby affirm that ihere is a conslruction lending agency for oy'�_ ,
the performance of the work for which this permit is iss�ed CONTRACTOR �
f5ec.3097,Civ.C.). � . . �
ADORESS ��.� Y �,.. . . . - . . _ . __-
Lender's Name � �
CITY yD TEL.NO. �O�/,
Lender's Address
STATE f p' LIC. '�
I certify that I have read ihis oppliw�ion and stale fhat Ihe UCENSE NO. J � / � CLASS � � � -� -- -
above informolion is correct.I agree to comply wilh oll Co�nly '
ordinances and S�ate laws rela�ing to building construction, _ ,, _, ._ _ _ .
and hereby aulhorize represenlatives af this County 10 enler .
upon�he o6ove-mentioned pr erty for inspection pvrposes. SEE REVFRSE FOR EXPLANATORY LANGUAGE
���-Y.� _ .
nar p�can�o�Ag>n� Da�e . . . . �. . . . - -
• � - • - •tws�eera��s t�oTes OWNER-aUILDER DECLARATION �
, - � " , , . .. ._ .. -I hereby offirm that I om exempt from the Coniracror's
'�, .�..• �• -
. . " � ' ' � ` License Law for ih^following rcoson (Setlion 7031.5,
... "_''.." _ ,
'...."�"' '.� .".. .... �.., . .. . .. . .-� ' �"�- � � --' . .-.__ .... ... . .. BuslnessandProlessionsCode):AnycityorcouNywhich
.i�, � � � �� . � , - � . requires a permil fo ronslruU,ol�er,Improve,demolish,
. �-- � - -� "' ' - " _ - ' � ' � or repeir any strurture, pnor fo ih Issuance, vlso re-
� _ , � , � ' , � � _ ,qulres Ihe epplimnt for such permlf to(ilc a sfgned sfote-
' � -� � - � - . � �, � � � menf Ihof he ie licensedpursuvnf to�hc provislons of fhe
' ,�— � Conlrocfor's llcense Law(Cfiapter 9(commondng wllh
�- �—�-�-��"-�� �� -� ���' '" � �� �� �'� ' ._ . � Secflon 7000J ol�'rvis�on 3 of the B�s7ness and.Profes�
. ' , , � slonz Code)or fhaf be/s exempt therelrom and�he bosis
, i� .� . , �� - _ • � � � � for the alleged exemptibn�Any violation of Secfion
� � '_ ,, . � � .- ��,��.� � 7031.5 by ony opplican�(or a perm7t su6(ecfs,fhe a pH-
, _ _.._ .. ._ __ . . . . ... .. � . . , P
. . , � � � - `� - �� mnt fo a dvlf penalty of nol more fhan five hvndred
i ,
.__ . ._.._ __ _ . . .. - . -. '
, - - � dollars(SSDO).: - �- ,-
_ __ , . . � � . - � .... �� 0 I,os owner of the property,will,do�he work,and
� - ihe strueture is nol intended or offcred for sale.
♦. - �� ' . . � � . . . , _
�--- --- - �� , � � � � ��(Sec.70A4,Buslness ondProfestlons Coder ihe Contrco
' , ', , � , �or's Ucensc Law does not apply!o on owner ol properfy
-� � � who bor�ds or lmproves thereon, and who does.such
r._. . .. __. .
� _ _ � �� work himseH provided fhat such improvemonls oro no�
' � � - � iNended or o!lered!or solo.If,howevcr,Ihe 6ulfding or
.. � , Improvemenf Is sold wlthin ono year ol compfelion,Ihe
. � -- �owner-bullderwll!hove fhe hurden ol proving�hal he did
, '_nof bulld or fmprove for fbe purposc of sofe.) ' ^
' � - � i O�I,as owner of tha property,am exdusively con-
. � . ,_ - tracting with licemed�con!ractori to construU the project
� � - - '�(Sec.7044)SusMess andProfesslons Code:The Controc-
.+ � �. i '�� ��or's llcense Law does nof epply fa an own^r of properfy
�� - - - ' who bullds or fmproves Ihereon,ond w6o ton}rocts(or
� � , � �. + - , � � sucb projects wilh a controcfor(s)licensed pursuan��o
_ ' fhe Confrodor i Gltense Low). � �
— I , ,
'• I am exempt�nder Sec.�' "
B&P.C.for this reason
. ... . .. . . .. ' �� Date
. � �� Owner .
- _. � ` � ., .
i. �
INSPECTOR'S NOTES