HomeMy WebLinkAbout1174A (5) WORKERS'COMPENSAiION DECLARATION � , APPLICAT�ON FOR P�ERMIT �
I hereby affirm ihat I have a cerlifimte of consent to self -
insore,or a ceriiiicate of Workeri Compensation i�s��a��e, ,bA3aac � HEATING - VENTILATING - AIR CONDITIONING �
or o certified cop thereoi(Sec.3800 Lab.C) �
�(/�����/�.�[, � CE-81B(REV.10/BI) . . . -- , G
OFy a. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished. �
�Certified copy is filed with the co�nty building inspeo- FOR APPLICANT TO FILL IN BUIIDING
fion deparfinenl. A�DRE55 � �'�
�PRINT OR TYPE ONCY) �
Da+e l�-G—S'7 APPIicaN r /3 iocnurn B
NO. TYPE OF APPLIAN�E OR EOUIPMENT � FEE "��
CERTIFICATE OF EXEMPTION FROM RKERS' nlEnaEST
COMPENSATION INSURANCE CRO5557.
(Thtt soefion naad nof be compl�}ed lf fha work involved by ABSORPTION UNIT,BTU DiSiRIC!NO. VRp�ES �er
tha parmll�s for ona hundrad dollatf(S1D0)or less.� qIR HANDIING UNIT,CFM � � I - �
1 certify thot in the performance of the work for which ihis (�[/
permil is issued,I shall not employ ony person in any manner gOILER,B7U
so as to become subjeU�o the Workers'Compensalion Laws. qvaaWnts DATE INSGECiOR'S SIGNAtURE
Da1e �pplicant COMPRESSOR,BTU ROUGH (�
NOTICE TO APPLICANT: If, after making this Cerlificate of vENTRATiON SvSrEM FlNnI �� ,L
Exemption, you should bemme subjecl to ihe Workers' �
� Compensation provisions of the Lobor Code,you must forth- EVAPOeaiNE COO�ER ' VALIDATION
wifh comply with such provisions or ihis permif sholl 6e
deemed fevoked. FURNACE: FAU RAVITY � � �
LICENSED CONTRACTORS DECLARATION � FlOOa BTU �' 'Y L'TJ
I hereby affirm�hat 1 am licensed under p�ovisions of Chopter 9 SU57ENDED UNIT_
��commenting with Section 7000)of Division 3 of 1he Business NEA7ER: WA��
and Professions Code,and my license is in(ull force and effecl. ' - ' >'
�/ 3 6- a �
0
License Number d+�yy/�C Lic Class e'Z V U
� Contracto�/�-L-����r- Dare /��"G"a"7 - , �
❑ I am exempt under Sec ' W
Plan check fee a.
B.BP.C.for this reason
Da�e: PERMIT ISSUING FEE S z 1 1 7,4 A . z
Signarore TOTAL FEE �1 �� ' • • •8
OWNER-BUIIDER DECLARATION PLAN CHECK APPLICANT ' I • � Q 4.7 S
I hereby affirm ihol I am eaempt from the CoNrocfor's License�
Law for the fol�owin9 reason(Section 7031.5,Business ond NAME ` • • � Q Il,7 rJ=
Professions Code): . - U
❑ I, os owne�Of ihe property, or my employees with ADDRESS � Q� 11—$�]
i
wpges as their sole compensofion,will do Ihe work and CITY TEL.NO.
Ihe structure is not intended or offered for sale($ection '�
7044,Business and Professions Code�. �/
OWNER/�l�f� ..J�
❑ �,as owner af ihe property,am exclusively contracting r^� '
with licensed contractors to construct the project(Sec• h���
tion 7044,Business and Professions Code). AD�RE55� ,� �
CONSTRUCTION LENDING AGENCY U7Y � � 7EL . � '- - _
I hereby oftirm that there is a constroction lend�ng agenty(or ° � �
the performance of the work for which this permit is issued CONiRA RS - L+J �
(Sea 3097,Civ.C.). . . .. ' . - . . . .
� � - ADDRE55 �. �l - - � _ .
Lender's Name •
. . � CITYO TEL.NO.9 �� .�� -. � .
Lender's Address �
STATE p UC.
I cerHfy thoi I have read this applimtion and staie�ha�the LICENSENO.� •/ s' � Ctn55 --�.Q -� � - � ..
above information is corrett.I agree�o comply with oll Co�nty �
ordinances and Slate lows reloting ro building conslruction, _ �
and here6y autharize rep�esentalives of this Counry b en�er � . � ' � � - -
u on the above-mennoned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE . ', .
�.� !<'6-Y7
'ignoNre of Applicont or Age ' Do�e - � � � ' " . ' -
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" '-j ` •' ' INSFECTOR'S NOTES OWNER-6UILDER D�CLARATION
_._.. � , •.
�. _ ' - 1 horeby atfirm���thaf I om ezompt�from the�Conlroaor's
'�s �-��- ' ��-�� � � License low for the following rcason (Setlfon 7031.5,
_,.' . .
.....�_..�._. ..
,.._. ...._. ._.._. .. . _ '_._ .._.. . . _.. _. _ . . ____ ... . . . . _ ... . 6usinessondProlessions CodeJ:AnyUlyormunrywhich
� � - , �� requirrs a permi��o consirun,abcr,improve,demolish.
- � � - •• ' ' - - � � - � -• �� � � ' or repoir_ony sfrudure, prior fo lfs lssuance, aleo re�
� . , - - __ �:qulros fhe applicanf for such perm/f fo(ile a slgnad s�afo�
- --� � -� - �- ' � � � �- ' - � � ' � � � ' � monl ihaf he is IicertsedpursuaN to fheproWslons o1 the
� , ` \ ��� , . Confrcclor's Lkensc Low(Chap�cr 9(commvncing wl�h
�� . . '��. y :
����-- ���- '�' ���� ��� ' '� �- �-� �� � ,._,.. . , Senlon 7000)of Division 3 0(the_Business and Profes�
.. � � � , � sions CodeJ or lhaf he is exemyf there(rom and fhe basis
� - � __ � - � (or 1he ofleged exemp�ion. Any violalion o(Sedlon
- � � ' � . � 7031.5 by cny opplimN!or a permi�subjecls fhc epph-
.. ._ .._. _- - -- --: . ._ _.
• , • . � con} �o a clvil penolfy of nof more ffion/ive hundred
. - - - — -. . .. .. . i � dolfars(5500):: . .
. .. _ .- ; t-.;;�� . __ _ . . _ ' � ' % ❑I,as owner of thc property will do the wcrk,ond
. -- , � . � "the struUure is not intcnd_d or offered for salc. .
. - __ --__ .. ' .__ _ . . (Sec.7044,6uslnessandProfess7onsCode: TheConfroc-
A , •• � ror i Ucense Law does not oppfy io an ovmcr ol properly
� � � � � who bailds or improves thereon, and who does sutb
, ,_. _ , . work hlmself provlded lhal such fmprovemeMs are not
� .. . � � � ��� � iNended or ofle�ed lor solc.If,howevcr,Ihe building or
_ � , � . Improvemcnl!s sold wffhin ono year o!complelion,ihe
� ' -- - - . ..... owner•builder wlll have!he hurden of proving fhaf he did ,
. � - , �not b�fld or Improve for fhe purpose of sale.)
� � � - � • ❑I,as owner of the properly,am exdusively con-
' � , '. � - ���iroc��ng wilh licensed conttoUors la'construU thc projeU
, � - -- -,.(Sec,7044)Business and Pro!essions Code�T6e Conlrcc-
. ', � � - .—for's License Law docs nof o�ply!o an oivner of properfy
' , ' ��- - who 6u1(ds or improves�hereon,and wha con7acts lor
� , ' ' ' ' � svch profects wilh a confroctor(s)ficensed pursuont�o
'. �,,1 � �' ' the Conlrador i L7cense!aw).
- . � � '♦ . _ ' _ . . . _ .
.. . .��.:) i • 1 � : . � . . .. . ._ .. � � I am exempl under Sec.
_ ,,, r . . , ,
� ' � - � B 8 P.C.for Ihis rcason �
' -i� :) V '- � - , �
. .. , � � Date �
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_.. _ . . _ . . _ _ . , , . . .. Owner
INSPECTOR'S NOTES �
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