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Home My WebLink About1173A (5) 1 WORKERS'COMPENSATIONDECLARATION . APP��'CATION FOR PLRMIT�. . � I hereby offNm that I have a certif(cate of consent to selF insure,or a certificate of Workers'Compensation Insurance, 76A�� HEATING - VENTILATING - AIR CONDITIONING ' or o certified copy thereof(Sec.3800,lab.C.) . - 3cS �CE-818(REV.l0ie1) � - - PolicyNo.--•• �vi—��y �1NU.�1VUGfi1vi12 � � � Ce�tified copy is he�eby furnished. �� COUNTY OF LOS ANGELES . BUI4DING AND SAFETY f If�--II� Certified topy is filed with the county buflding Inspeo- FOR APPLICANT 70 FI�L IN � BWLDING q T7� lion deparlmenl. � (PRINT OR TYPE ONIY) � ADORE55 p��J70�}C .r/fly� �7— oate lU—o-25! qPP�i�a�� SAN'1'IP.GO A/C IOCALITY � - l NO. TYPE OF APPLIANCE OR EQUIPMENT � . FEE �'`� CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST ' e , COMPENSATION INSURANCE Crt055 ST. �� j � (Thi�t�cfion no�d not b�compl�fad if th�work Involr�d by ABSORPTION UNIT,BTU DiSiRICi NO. VRpCE55ED r th�p�rmit Is for on�hundnd dollarS(S�QOJ o�Ioss.J � qIR HANDLING UNIT,CFM - '� � I I certify that in the performonce of the work for which this I permil is issued,I shall nof employ any pe�son in any manner BOILER,BTU i so as fo hecome subject to Ihe Workers'Compensation Laws. avvaovats oni¢ INSPECTOR'S$ICNAiURE � Dote /+pplicant COMPRESSOR,BTU ROUGH � �� NOTICE TO APPIICANT: If, ofier moking this Certificaie of VENTIIATION SYSTEM FINAL ��F��" � Exemp�ion, you should become subject to the Workers' Compensarion provisions of the Labor Code,you mu51(orlh- EVAPORATNE COOIER ' VALIDATION � with comply wilh such provisions or this permit shall be deemed re�oked. �. FURNACF. fAU GRAV TY � � LICENSED CONTRACiORS DECLARATION FLOOR Biu I hereby affirm Ihot I om licensed under provisions of Chopler 9 HEATER: SUSCENDED UNIT_ - . '(commencing wi�h SeUion 7000)of Division 3 of the Business WA« � and Pmfessions Code,and my license is in full force and effect. � • ' � �' c'� �S a. � licenseNumber GV=�'ly6 Lic.Clau �.---.� � � , � (�J com�o�to� SANTIAGO A/C po�e 10-6-87 � 0 ❑ I am exempt under Sec. .. _ � � w Plan check fee N B.BP.C.for Ihis reason- PERMIT ISSUING FEE; (� 3— .j-'1 1 7.3 A � Da1e: S�9�oru.e TOTAL FEE 7 �• . � . .£y � OWNER-BUIIDER DECLARATION ' PtaN CHECK APPUCnNT I • j O�7.7 Jr I hereby affirm thal I am exempf irom ihe Confrotlor'S license , low fo��he following reason(Secfion 7031.5,Business ond NAME � , Professions Code): ' • • � ��'7 5� ❑ I, os owner of the propeny, or my employees wiih ADORE55 ages as their sole compensarion,will do the work and 'a�4—$7 Ihe sfrutfure is not infended or offered for sale(Section CITY TEL.NO. 7044,BusinessandProfessionsCode). 'j`Fjj��' WILLIAM LYON C�. OWNER ❑ I,os owner of ihe properly,am exclusively contraUing wilh I�Censed contrpclors b construcl Ihe prajeU(Sec- DDRE55 19 CORPORATE PLAZA � tion 7044,Business and Professions Code).� � CONSTRUCTION IENDING AGENCY ��TY NEWPORT BEACA TEL.NO. -� � ��' I hereby affirm that there(s a construcfion lending agenty(or , the perTormante of the work tor which fbis permif is issoed CONTRACTOR SANTIAGO A �.` � � -- � (Set.3097.Civ.C.). . ' � . .. .. � . - ADDRE55 231 W. BLUERIDGE AVE.� - . . . . . . . . lender's Nome , � Lender's Address � c�TM ORANGE �E�."o -5:98-1600 - 1 certify thot I hove read lhis applicotion ond state Ihal the iiceNse N�69496 CLA55 r.—`Z� -�- � . . _. obove informatian is correct.1 agree to comply wilh all Counly . ordinances and Sto�e laws rela�ing to building consiruc�ion, . . . . . _ . . .. . . and here6y au�horize representa�ives of this Counfy to eNer , � � - - � upon�he above-meM�oned propery for inspection purposes. . . SEE REVERSE FOR EXPLANATORY LANGUAGE . . - . . . /(rG,-5 � ignarure a1 ApPlicant or Agenr Date - . . . . . . . .. . . .. -. . . - � ' � - � • �INSPEC70P.'S NOTES OWNER-6UILDER DECLARATION . � ' � I�h�oreby bffirm tha'1 am�exempl frorA'the Contractor's � ' ' '' '' � ' ' licensa Law for the following reoson (SecMon 703I.5, �,.. . ._.._ ..._..�........_._. .-.._._.._...... . ._. . . ..._..,_� . ... . _ . . . _'_...a' , .� •.•. n Qusfness o d Proless/ons Code):Any city or munry which � � -�t � . ' . ' � � requlros o permil to mnsfrucf,olMr,(mprove,demolish, j-"- � �- ��- � - � �� ,� � . - ". � � ' or repclr any sfructure,pAor to!ts Issuonca, o(so re� ' � ', , , ' , - . .�qufros th3 applicanl for such permlt�0 1tle o elgned sfafr �. ..___.. . __. -_. � �� __._ . � , � . � , ment lfiai he Is licensad pursua.a�fo fhe provlslonz ol thc �.� . , . Conlracfor's Lkense low(Chap�cr 9(mmmertcing wl�h � �� , � � ' • �� " . � � 5ectlon 7000)of�Division 3 of fhe Dusfness and Pro/es- I . � , � sions CodeJ or that he Is exemp�rherclrom ond ihe 6asrs � � - . � -: . ' . . " � for Ihc ailcyed c mpfion. Any vlo�olion of Secfion _ xe ,___, ,_ , ..____,_ __ _ _ _ _ _ _ � 7031.5 by any applicant for a permi�subjects the oppli- i . . . . ' - � � � � .cane fo.o�civ�l penolty of nof more ihan flve hundred --— ---- �---� --- - . . . ' � dalfors(5500).: �' , 1 ' �! . ' - � � � � � �I,os owner of the prope,rry will do ihe wo�k,.ond � - � � � . -ihe sirutlure is noi in�ended or offcred for sole. —--- - � - �— - � -- --- � (Sec.7044,Buslness and Prolesstons Code: 7he Confrac- !"" �' , . �. •for's License law does no}opply�o on owner of properiy �� - - � � . who bullds ar improves Ihcreon, ond who does such �. � � - , work himsell provided�ha�such improvemenis are nof � , � - " iNended or ol/ered lor salc.If,however,Ihe building or . - improvemenf is sold wRhin one year of complotion,�be � - ' owner-butlder w711 fiavc Ific burdvn oi proving that ho did � , , nof build or lmprove for fhe pvrpose oi salo.) . , " ' � � � ❑I,os owner of iho prope�iy,am exclosively con- � • - trocting with licensed contractors�o cons�ruU the pro;eci - - (Scc 7044)Gus7ness and Professians Code:Thc Confrac . � ' for's License Low does nof opply fo�an owncr ol prope�ty - � - who bWlds or Improves ihweon,and who conlroUs,!or ' ' � ' - suth projecfs w(fh a confracfor(sf lkensed pursuant to - , � � ✓ fhe Controctor's license Law).� ' . . . . Fj _. .. _ � _' . . . . ._ . . � . . _ _. - .. .. -. . . ,� � , � � - � I am exempl under Sec. - - ' � ��-� � ' B&P.C.for this reason� � , —t� � i� l , — ---- ... _ . ,-�-- .� � � . . Datc � . . , ' � - - --�-- -. ._ . � .. . . . _ . _ Owner INSPECTOR'S NOTES - �� - ' - -- � .� . � , . . - .. ,�� ,