HomeMy WebLinkAbout1635A (9) - WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT • �
1'hereti'y offnm ihpt I have a certificole of consent fo self �
insure,or o certifimte oi Workeri Compensotion i�5��a��e,'�.. - - HEATING -�VENTILATING - AIR CON[11TIONING
. or a certified copy�hereof(Sec.3800,La .�C.) 76A364C � ' .
�3 ot7o—!�g � ee:eia�aev.io�ei> _
POolicy N mpany COUNTY OF LO$ANGELE$ BUILDING AND SAFETY
Certified copy is hereby furnished. �
� � Cer�ified copy is Eled wiih the couniy 6uilding inspec• FOR APPLICANT TO FILL IN BUuowG
fion department. � � /� t (PRIM OR TYPE ONLY) ADDRE55
Da�e s �4 APPlimnt a""o �-�+v�}� IOC.^.IITV �
CERTIFICATE OF EXEMPTION FROM WORKER$" NO. TYPE OF APPLIANCE OR EOUIPMENT fEE
NEAREST
COMPENSATION INSURANCE CROSSST.
�TFIIf iYC1I011 IIP6E 1101 bY COTPI�}61I If}IIY WOfIt IfIVO�V�d by � ABSORPTION UNIT,BTU DISTRiCT NO. , OROCESSEO BY
the parmit is for on�hundnd dollors(f100)or less.) qIR HANDIING UNIT,CfM � /�
I certify Ihot in ihe performance of the work for which this
permit is iss�ed,I sholl no�employ any person in any manner gp�LER,eTU APVROVAlS nte I SiECT 'S SIGNATURE
sa as to become subject)o the Workers'Compensation Laws.
Date �pplicant COMPRESSOR,BTU ROUGH Q
NOTICE TO APPIICANT: If, after making this Cerli(icote of VENTILATION SYSTEM FINAL , �
Exemprion, you should become subject to the Workers'
Compensalion provisions oi Ihe labor Code,�you mvst forih- EVAPORATIVE COOLER . ��. VALIDATION
with comply with such provisians or this permit shall be �'.
� �deemed revoked. � � FURNACE: FAU_GRAVITY �
LICENSED CONTRACiORS DECLARATION FLOOR BTU � ��
I here6y aifirm that I am licensed under provisiont of Chapter 9 HEn7ER: SUSPENDE� UNR_ �'�
'(commencing with Section 7000)of Division 3 of the Business 'NA« �, }
and Professions Code,and my license is in full force and effect: _ �� �� � O � , O
License Number '4�70 lic.Class� � B � � ► , V
a
Contrattor�ro�q9ate 8 11-86 ' �
❑ I am exempf under Set. . -5�-� 6 3 S A V �
Plan check fee W
a
�
0.8P.G.far thrs reason pERMIT ISSUING FEE S �0 3 L \ #�+ + •�� Z
Date: TOTAL FEE �-lp � • •G Q rJ O
Signalure - � '. �
OWNER-BUIIDER DECLARATION PiAN CrfECK APauCnM . . , � • ' °�0..�+O�
I hereby affirm thal i am exempt from the Controctor's License '
Law for the following reason(Section 7031.5, Business and NAMe ► ' �9.ri 5�8 6 .
Professions Code): - �, .
� ❑ I, as owner of the p�opeily, or my employees with AD�RE55 7�� � �. �
wages as their sole compensa�ion,will do the work ond ��TY TEL NO. � �
the strudure is nat iniended or offered tor sole(Section n4 5�18�
7044,Business and Professions Code). . � �
OWNER
❑ I,as owner of Ihe property,am eadusively mniracting �` � .
wilh licensed contrpUors fo construct Ihe project(Sec- AD�RE55 1763 C:lifE�z Igi�e �� � �
tion 7044,Business and Professions Code). ' �. -
CONSTRUCTION LENDING AGENCY - CiTY ����Y. � TEI.NO�n4� S'E1�I�.Z
I hereby affirm thai Ihere is a constrpction lending agenq for , .
1he performonce of Ihe work for which Ihis permit is issued CONTRnC70R
(Sec.3097,Civ.C.). . � . � - � -
ADDRE55 � ��� � � �
Lender's Name
CITY TEL NO. , . . . , _ . .
Lender's Address '
STATE IIC. . '
I certify ihot I have read Ihis applicolion and state thot the LICENSE NO. � � C1A55 � � ��� - -- - - - �
above information i;correct.I ogree to mmply wi�h all County '�, _
inonces ond State lows relaling ta bui�ding construction, . , _ ., _
n hereby au�horize representatives of this Counly to enter �
n the�ybov entioned property for inspeuion purposes. - SEE REVERSE FOR EXPLANATORY LANGUAGE �
.e�._:'1" •�o..�-.� 8-11-$�
$i9nature of ApplicoN or Agent Dole ' . . . . . _ . . . - .
` " '' ' ' - IN��ECTOR'S N07E5 OWNER-GUILDER DECLARATION
' � � � I hereby affirm tha�t am"exempt from ihe Convactor's
-� �� � � � ' ' License Low for the following rcasan (Sedion 7031.5,
_..__..._.__..._�_._...._._. ...... _
. ' ""' _ . . ... ... .._..
, . --� - " �-� �� "' �'- " -�-' BvsinessandPro(esslonsCo e):Anycityormunlyw Ic�
� . . � � ' - ' � � iequ/res a permu ro construc�,ol�er,tmprove."derqofish,
� ��� � � -��� � ���---- ' ��" �' �� � � ' � or repatr any structure, prior to its Issuanm,.alze re-
, � �� ��- _ . ' "_"'quirez}he oppllcanl for svch permll lo file o signed sfole-
' .. . _ _._ . _ ___._ � . �
- � � ' � menl fhat he Is IfcensedpursucN fo Ihe provislons of the
r
� � , � � Conlrador�s lfconse Law(Cfiapfer 9(rommencing with
�.__" _._.�_-_.__..,.._.... �.
� " � - ' � � ' Sectlon 7000J ol Divis�on 3 a(�he Business and Profes- �
, 3ions Code)or fhof he is csempf fherefrom and the basis
. ' , ��, .�� . ' � � � " (or 16e afleged exemption. Any vlofofion o(Sectlon
� _ . ,._. _ ._ _ ._. _ . . .. , , 703L5 6y any appllcaN lo�a permlf subjecls fhe appli�
� .. . � � . _ � conf fo a clvil ponolfy of no1 morc lhan flvc hundred
` ', `'1: . . . , . . dollan(5500).: � .
� :�. �� •'-�.�`�.� ��' ,�'�. � � � - ' � � ❑I,os owner of the property will do the work,and
.. _ ._. . .... _ . ._ . .._ .__ __..... . . . .
, . � . � „ . Ihe strucNre is not iNend�d or offered for salo.
' - ---- � � �� --• � -�� - � - --, � � �� (Sec.7044,8usiness and Prolessions Code: 7he CoMroc-
r. � " , . tor i Clcense Law does not appfy to dn owner ol property
- � ' � � who builds or Improves fhereon, and who does.such
' �. . . . �.- � work hlmscl/pravided�hat such Improvemenfs are nof
, - � � in�ended or olfered for sale.If,howevcr,ihe bWlding or
-. . . .. �. , . improvemenf Is sold wi�hin ono year ol comp/o0on.thc
_ _ -- �� � - _ _ ' � owner-butlderwJll have�hc burden of proving�ha�he d�d
� ' nof 6ulld o�Improve(or fhe purpose of sole.) -�
� - - � � ' - - - ' � � ❑I,as owner of the property,am exclusively com
� ' � - -trocting wilh licensed conhotlors io consirutl 1he projc<r
� - - - - �(S�c.7Qd4f 6uslness and Pro(essions Code:The Controe
, � ' ' lor's Ucensc Low does nol appfy to an owner ol property
' , � - ' - - - - ' who bul(ds or improves t6ereon,and who confrecfs Ior
� � � _ " - _ � such projects wft6 a contratlor(s)licensed pursuan�fo
' '� � - the Confrador's License LawJ.
� � - � I am exempt under Sec. �
� � � - � B&P.C.for this reason � �
- - - - .. Dofe
' _ _ . _ ' � � . . �. . . _ ._ . . Owner �
. � �i � ��� .. '. � _ . . . .,. . .
. . �� --- —� .�.,. . .... ---. . .. . ., . � . ,
INSPECTOR'S NOTES ' �
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