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HomeMy WebLinkAbout1585A � - WORKERS'COMPENSATION DECLARATION -� � �� J w pp /�/� � w'"C' `�p pep �T '-� - - I hereby offlrm Ihot I have a certifimte of consent to sel{ �j '•� . � Mf f���.rM�'o1� f OR • GR��• , _. ._� nsure,or o certificate of Workers'Comp nsation Insuronce, ' ` ""-�" � ' or a certfie copy�hereof�lSe<.3800�,�� .C.) ,.i" �y+3eec �. . - HEATING - VENTfIATING • AIR�COI�bITI�1�T�'G� �r��-e,e�aev.,o;en Pol' N ��mpany COUNTY OF LOS ANGELES BUILDING AND SAFETY Certifiied copy is�hereby furnished. � . . �.._. .. . . ....,:.,.., _ „�.:.� �N. . .....,.�-< <_._._: ... .,.. � Certitied copy is filed with the co �ty building ins ec- FOR APPLICANT�TO FILL 1N-� ����� eW�o�NG � � tion deparfiney�t. (PRINT OR TYPE OIJLY) ADDRES d �� �� �� Da+�. —�T APpliean e , . -- .. ..... _. LODUTv � . NO. TYPE OF APP!tANCE OR f�UIPMENT fEE CERTIFICATE OF EXEMPTION FROM W(3RKE�5' '��� -----�- �.---- . uEnRe57 COMPENSATION INSURANCE � CROSS 5T. � SI�- � /`J (This section need oof be complefed ifi ehe work involved 6y� Ae50RMiOn'UNIL siu - ,is*a:cT No.- a CESSED BY/ fhe permit is for one hondred dollars(§100}�or less.)�� . .. . � . � �I certiPy��thot in the performonce of the WOfK�fOY which this AIR HANDLING L1NIT,CFM �� permii is issued,1 sholl nol employ any person in any monner gpILER,BTU � so as to become subject to the Workers'Compensarion Laws. . � AP�Rovnts oATe ':nSPEcrou�5 sicNaiuee Date�-�- ���-- ----.Applimnt � � � COMPRES50R;BTU� � - � � ROUGH -NOTICE TO APPLICANT: 14, �fier making�ihis�Cerlificote of �� b'ENTiLATiON SYSTEM FINAL ��^�' Exemption, you should be<ome subject io ihe Workers' -� � CompEntation provisions of the LaUor Code,you must forth- � EVAPORA7IVE COOLER --� �� � �� ,/ALID/�TIQN . wi�h �ompiy w th soch pr�ovisions or�this permif shall be � deemed revoked. � FURNACE' FAU G y�ITY -� ",� � LICENSED CONTRACTORS DECLARATION FLOOR � 6?U �� v ' I herehy offirm fhoY I�arp licensed under-provisions of Chapter 9 HEATER: SUSPENDED UNIT_ � �icommencing wiih Seciion 7000)ot Division�3 of the Bus�ness - � "�� "`'Ai� _ , and ProfessYons;"Cod/e,and my license s m#ull force ond effed . - � . : �c',C f( �j �,_2� � / % � c7 ;5 z1 %,�fi p License Nu � /�'l��✓ Lic Closs � - - - ► � j �y�es m o .�,4 � Contracf r 'm� �" �._ �alersce=�`—L.. . .'�.o s-J�(�.i S O . D _ �,� ; r � I om ezempi under Sec -� ���� P�Gn ChOCk fee o a u,�j ��q �^h � B.&P.C.for this.ceds"on:.. . �� . . .... . c•� � � ;- PERMIT ISSUING FEE S,, (�J, — Date:-� -. . . 5gnature � r'' TOTAL FEE ,j OWNER-BUILDER D�CLARATION� � G!AN CHECK APPIICANT�- � - - � � I hereby atfirm that I am exempt from the Conlractor's License ����� -�� �� �������^- , . Low for the follpwing reoson(Se<t on 70$1.5, Business and NnncE - Professions Code1: . . � - - �� � ��- �'� ❑ I, as owner of fhe prdperty, or my employees with ADDRF55 � � wages as their sole compensotion,will do the vaork and �,TY _ � 'E�.NO-� the strudure is�nat intended or offered tor sale{Section 70dd,Boslness and Professions Code).� � . . � � � - � - � � . OWNER ❑ I,as owner of the properfy,om exdusively contrading . "_���-• -` - with licensed ron!ractors to consirucf the project!Sec- qDDRE55 - ' fion 7044,Business and Professons Code). �'�"�- - ' � CONSTRUCTION IEND!NG AGENCY . CITv� � � TEL h0: - � � � I hereby aff rm thaf�here is a construc�ion Iending agency for . � . �� - ���--- -� . ihe performonce of rhe wo�k for which this ermit is issued CON?RAC70R � ��� � !Sec.3097,C v.C � /� . . . .. �- - . . . G/� °! G ADDRE55 .r.3.u: !^✓''75..� . . . � . . ._ Lender's Name � � . . O � /9i Aj .C� � L�/D�j CITV � TEL NO 71 t�� _ Lender's Addres�i� ..... __.. _ _.._ ,. . . . —� STATE //fj p ..���C I certify ihot I have�ead this applimtion ond sfate tho+�he UCENSE NO �7J� �@� �CLA55 —�� . above information s rorrec+ I ogree io comply wdh o I Counry �� ��/G��.,�Y� - , � ord�nances ond Sta�e laws relaf ng to bv'Id�ing canstruchon, 7 .� . . . .. . ... and he�e6y outhanze r resentA+ives of ih�s County to enter � - �n „Qyyy�� � 9.2$'0.,3 . . . . . �po th bove mem ed ert�� r'nspection purposes. SEE REVERSE FOR EXPC�ANATORY LANGUAGE . _�, - .. $ionature r,f AOFI��anf or Aga r pote - � _ _ . _. _ _,�.:.I�SPECiQ�'S Fl4TES OW�iER-BUI�RER D�CLA�ATI��1 . - . . � � � I here6��a'firm�ihas�l nm-exemot from ti:z Controctor's � ' . �'` . �,�.�:. .�. . ��.�� '......--. ,' . ._.' .- . .. ... . . Liceese.'-cw�for +he.fo"o,�ica aason jSec!ion .'03i.5. '- � � . � - � � � - " - � � - - - - - � � � � � ' � - 6usir,ess ond Professions Code;:Any ity or munry v rtich . ...' �,�.•.'":. "...�"'•-.�:' . �.- . .. :. , "-requires a per i.ta c�r,;l{ucf,cher.improve,demolish. - � - ' � - -� - � - ' � � ' or repair ary siructure, rr�ar�o its i;suance, a!so re- _ - . � - - � ' � � - -���.-> :{-�.��.-quir=s!Fe app/icant ror su-h pe:mli-'ro 4f1e a signed stclt- � . �. �- � ... .. .. . � �� .. . . -....._ �:.��. . .. . . . . . . -� menf!fio;he is ficensed pursuunf to the p:-cvisi�rs of sh� - - . - � � � - . . � �� Coniroc3or's Frcense!Dw(Cho�ter S.'corr+mentiny wirb - � � - - �� � -�"`_ .. - �- - Sec"ron i0J'J;of O�vi=_fen 3 oi'he&usmass cnd Proles- � � , ' � . sions�Codel o tha}he:s exempt ih�eF_fror,�vnd 7n 't�osis ' � - - - � for the cilagec exemaP'or,._i1r,y v�o;etrcn of SecSlon ��� � � - ^ 7031.�.Sy cny op�liconi-fcr o p�rmif subjects fhe cppli- . � � . � `- _:'.__ _ �. . . . . _ .. .. _____ . . .. .�.�- . . .. . . . � � � � - � _ - - � can,`to a cWil pendlfy_ot na;�m.ore'han five hur.dred ��--... . . . . . _ . .. . . - . - de!lors�SSOOi.: �� _ . . .. :.... . ,: . - .. . . � ' , . . . ❑I,cs o�.��c-of��c oroAzr,y w o ihe v:c k.-r.,, . . .. ... _ .- . . . . . . . . - . �� e srructurz is ror intecrdc-o c•.of�e:ed`o�sde. . � � - � �� - � � � � !Sec.7044,4vsiness and?rofess%ons C4de: �Thz�ConFrcc- � . `.� � . . . �� �. . . tor's Ricer.se Lary d�es,nof app!y fo an cwner of�proparty � �� . � - �who b¢iJcs cr improves (Lereon, vr.d v✓ho does such � � . _. .. �-�� • ������ -����--����- �--: - . svoric himsef¢provided fnct socFr improvamenis cre noi_ � . � - � � intenaed or orfered fcr safe.ff.hc,v✓ev:�r,She 6uif�ing u ��-��. . . .-' - . , . . . : -. improvem�nt is so;d yriPhin.pne�year of comple?'ror.,ibe � - ownar-builder will nave fhe burdert of proving ihot he d±d -� - - . -- -� - � �-��� -� . not buifd or improve£er�P3re purpo;e-o4 sofe.; - - � � . " � ��.�f,os owner of9Fe prooarly,�cm exclus�voly con- . , - . � � - - - iro ti g v�ith licenseo-co,'�P ccic�s b�c ns r,�ci?he�arojec� . - - - � � iSec,.7044j Eusiness and?{o4esslons CoCe:The Ccntroc- � '. - � � ���- �'�-�� !c L¢ense'.cw does not 6ppfy fo,n owncr of proper;y - � � � - � who buNds or im,crovcs.7herean,q�:d who contrac?�ior � � � � - ���"-" �"-- � such projects wiih a con9ractor!sj licensed pursuari ic - - fhe Ceniracior's Cicense Lcv.;�: � � � � . . . . .._. _ ...__. .:_._._._. .._.. .__ _ . . . � - - - � I am exemot under Sec. � - 8�P.C.#or this recson � � . . Date---- . . . .. . . ^�---. '�,•-: �.-:o�.- � , ••-- - _ _ Oa n r , .� __ , ,,., , . __: iP�lSPEC7'OR'S 4NQTES _ _ , - ._ . ;,.. w,. _�:, ._,.: _ : : _ . _. . . _.:.,::,;.._ ___.:.�_:;.__..�.-e-�..t=� ...-,o..,>:_...:....,._.�.-.::<:�.n.a,..li�.:,...z�: _ _�:�� ._.;�� ...n-;�-_.,»�vca•r.�.r„ � - .