HomeMy WebLinkAbout1586A WORKERS'COMPENSAiION DECLARATION ... .`. '� ,'G ... . �..... _.�. �. . ':: " ` �. ..�` . �". .-.:..� _... ... � I hereby affirm Ihat I have o certrfimte of mnseni lo self o • APPLICATIO�N �OR PERNIIT insure,or a certificare of Workers'Co nsation insurance, HEATING - VENTILI�TCNG - AIR CONDITI�NING or o cerfified mpy fhereof(Sec.380 .C.) ��'3� - . � �_ �- � . - ��p�� KK--�'�' �.�`E-8te(REV.70/61;� � Poli No�[�1.Z(o��mpany � '�"" . � - �Certified co is hereb fumishe . COUNTY OF LOS ANGEL�S BUILDING AND SAFE?Y PY� Y .<d.�:_...-..�e„�.m�a.,, � - •< ..._-, . ._.>�.. - r c3^�.�'_...,..__,., .,_, � Certified copy is fil�d with rhe bulldin ��spe/o-'� FOR APPLICANT TO FILL IN�� � � euao�iNc� - .� � J� � ��/ tion deparfine t. � (vRINT Ok TYPE ONLY� ADDRE55 �jfyj DaL3��APPlican _... ��.... LOCALITV / �� . NO. TYPE OF APP;iANCE OR EC�UIPMENT� . FFE CERTIFICATE OF EXEMPiION'FRO+N VJORKEP.S �� � . NEARE57 / -I COMPENSATION�IN�URATJCE` � � . CRO55 ST. � �q Q�' ,��f y (This secfion need not bo complefad i{1he work involvod by ABSORPTiON UNIT,BTU c•isre�cr No. ��- - =aoces� r ibe permit is for one hundred dollors(5100)or kss,)� . . . . . I.certify that in the performance�of(he�work foi which ihis /�R HANDLING UNIT.CHJ� �permil i5 issued,1 sholl not employ any person in ony monner �� - so asio become subjecf to-the Workers'Compensolion Laws. BOILER,B7U qpvRpva�s enre wsPecrou'<5!Gvnruae Date - Applicant - � COMPRESSOR,BTU Qv� � (� ROUGH NOTICE TO APPLICANT' If,-d�ter��making ihis Certlflcote of VENiILATION 5YSTEM� � - - FINAL Exempiion, you�should become�subject to� the� Workers' . . . � � Compensdtion provisions of�he Labar Code,you.must forth- . EVAPORATNE[OO�ea VALIDATION with comply with s�ch provisions�or rhis permi� shall be deemed revoked. - FIJRNAC�: -F/U GRAVITv - �---- LICENSED CONTRACiORS�DECLARATION� - ��� � FLOOR BTU � i he�eby affirm thol f am licensed under provisions of Chapter 9 HEA?ER: SUSPENDEC � UNIT�_ ��commencing with Section 700Dj of�ivision 3 of the B�siness _ WA�� . and Professions Code,and my license is in full force ond effect. � g 3���� � o� �f'� .�i 7 8.h A E9 License Numb Lic.Closs . � , � - � /3�.p�.v �ate e�3/a�—�� �,1 0 � • c e R�, . � Controctor • - . ❑ I am exempt under Sec. - � . t e y��y C W Plan check fee � aoa�1.��= '� 8.8P:C.for thls reason PERMIT ISSUING FEE$ g �ote: ...".. � U 5 I S'-'2 4 Sig�ature TOTAI FEE �/ �j' OWNER-BUILDER DECLARATION - PLAN CuE:K aacLlCaNi ��� - . �� I hereby affirm ihot I am exempt from the Contra<tar's License�� . ��� - �---- �� -� ► - � Low for Ihe following reason (Sedion 7037.5, Business and NAME � . � ProfessionsCode}: . - �� ��-'����� ❑ I, os owner of the property, or my employees wiih ADDRE55 " . woges os iheir sole mmpenso:ion�,will do the work and . C!TY tEL NO. � � � . � ihe sirudure is not intended or�offered for�sale(Secfion _.._ ._. 7044,8uslnes5 and Professions-Ccde). � . OWNER ❑ I,as owner of ihe properfy,am exdusively con!rading �--•- � ��� � -- . wilh licensed contractors to construU fhe project;Seo- �"'»�'� tion 7044,Business and Professfons{ode?. AD�RE55 , . , - CONSTP,UCTION LENDING AGEN�Y C�?Y� TEC:NO.-� � � I here6ynffirm lhot ihere is o mnsir�ction lending agency for ► . ihe performan<e of�he work for.which rhis permit is issued ��NTRaC70R-- � (Sec.3097,Civ.C L /+ . _ - �. � �i��•. 'T!G . ADDRESS. �, �'��— ' � . Lender's Nom ' Lender's Address � /� � � � Ciiv -Q.y� ?el.NO. /-.',, _ �—�"'D7�"'� . � 5T.41E !�C. I certify that I hove read this application and sta'e thof ihe LICENSE NO.� � -� �_ � � ClASS �- - . above informoti9n is mrrect.I agree to comply with oll Coumy � . - � .ordinances ond Sta�e lows relating ta building ronstrucrion, - .- _. ; _ . _ . _ . -ond he�eby authorize r reseNotives of�his County to¢nter - - .,. . . �. r erty for inspection purp es. "'"'�' � �� � `� � - � ugo e ove-m eeG� SEE REVERSE FOR EXPLANATORY Ll1NGUAGE . / _ ��-�� . _ SignoYvre of Appl!ca�t or Agen' Da!e - � - - _.., _ , tNSFE�T�R'3 t3�T� QVJNER-BUiLB€R;�ECLAP,AT!s N . : . . . .. � Y I he:eby offirm 7hat i am�exemcbrrom ihe Contrcdcr's . ��-� .. . . - . ..-�� �.-. :-. -.=.. - --:. .. . . . . �icen;a i_cw ior <ha fo��o:+inr reoson.(Sectio� 7d3;.5. .... . .. . . :. . _ . . .. .. . ....__�_,..._... ... .._. . , __.. 8usinzss ano?rofe srens Code, y c,r;r o�co�rty�uhirh . . . . .. .. ,,,,,,,,,, ,,,,,,,,,,,�. . �— .. raquires o permil fo cort,trucf,c ar,mnrove,�demolish, - - - - � . or repair ony strucfure, prio�fo rts iruarce,,clso re _._...... . . . .. . .. ... .-_ . . .... . .. . . - - � . . . � -� - � - � ----� ��-.-<- -.quites the app/fccnt ior sueh perrriP ro fife c signzdsiafe- - - - ---� � � -- `� - --- � � � � � - � � mani thvt he is lice;sed purstienS f-�the prevuions cf fhe ' � . . . _ � - . - Cer.tro;or's iicens�+�tow(Chapter-9(ccmmenung wiih . '_ -•>.. �.- , . . . . � . � ' � �- �- � ` '�-'��- `-----���� �--� - - - Seciion 7C�3Gj ofLrvislon 3 of h .6usiness ano Proies- - '� �. . � � - -�� � . �� sions,Code1 or th�ct he�s zxt,�ipt 7hcrefrom ar-.d ihe basis � - � - - � � - - for ;he.aileged exc-piicrt.. Aay vroic£on o6�Seef;on . . �-^.... - ,-'�- . . . . � � _. . . 703L5 by any ap�;¢cn7_for a pormi7 subjecfs 4he eppli- . , _. . _ . ._ .. _ . � ....: ___ ___. - . . . : _ . . . . � ..,..:.. . ..,... - ��-� - � canf 1v c civii'-penal!;�of nof more.,"fian irve.hundred _ . .,,., , , : .._. .-:� . . . . __ .,. . . dollo,s:,'S300;.._ . .. . -.. . . . -_ . - _- .. . ._� . . . . - . .. - � . u I.cs o�.me f.h�rrcpe t v/�I:uo t e ., _r.d cr•c,- . .. . .".. . .. ... . . ... :. .- � � . . .. . .. ..he s:ructure is cct in:=nocd-or o�a:ed'cr saie. .. . ' -.. . . - _. . . . � . .. ... � �(Sad�7C44,?usiness nd.Proiessions Cede. il7e ConTrco �-� � ��-�. � � -� - -. tor's('cense Cvvr d as r,of appiy to o7�ownar ot ptoperty . -.- . - . .' � . - . . .. . . - who 6�'fds.�cr i.mp ovzs.thv,.recn,-aqd.urho�c'o2s such . � . - . . . . ,.. . . or!c h'mself p;c -ded nc�o su h improvemarrts qre r,c' w -. � . � .. i�tended or o`fered for sc(a.If ho _ver,.- `�.,iidtr.g or - � �- . - - . . .. improvprt�=n4 is sold w;th'rn c� yac:o`camplet,'on,`:h.� � � � - � owner bui(d�r wi;!hcva 1na ku�den of pro�iing iFvt he c:d - � - � --� �- � � - �--. no9 buiid or imerore��for ihe buraosebf soier) - � . - - : . � � . ...___ . 'rl!,as ov✓ner of!he-proparty,oT�exclusively<cn- . � octing�rt^;icens c-_ �±�ac? . onst � -�.tip b =c� r o: '�c ro; � � ' - ° •� - ____ . !Sec 7C44;3usiress and Professions�:,de�7he C ��tr_o- � . �for's�License��av�d e � � :a;aprly ro on oK�ner of prop�r?� - - �- ' ' _ - wha build,or imprc °ereon,ard u�horo. ocis for _ v�s i� _ _._. . � . `..-.:-.' . .•' s�ch-p ojec7s with a contrccPor�sj(ircn>ed�pu'suan<io � - � � - � - - ihe Centractor�s iicer,se Lcw^. � ` . . _ . -_.__.._._. ... . . .. ._ ._. .... .__.. _..._ ..._._. � :. � � � I am exemo�under S..c.___ -_—__ � - B t�F.C_for ihis recson .. _ . ._ .. . . — . Date - �.-- ----- — . .. . �_;. .. . . , �:...._: :. . - � . .. - .__. .. . flviner_, . � _-:_. . . . ,-. . . . _. ._ . ,:_F.- - _ ._ . . . . . INSPECT�R'S N08ES . �_. . , . � ; � .:_. � � � >� _,'�xT, ,.�,�.,< � -.,.:- �- -' �. .uzz .:.o ,. ,�.. .�:,.;; . ._.,._,