HomeMy WebLinkAbout1172A WORKERS'COMPENS,>TIONDECIARATION APPLICATION FOR PERMIT
I hereby affirm tho�I have a certifica�e of consent to seff � �� �
insure,or a certifita�e of Workers'Compensation Insurance, �bA�� HEATING - VENTILATING - AIR CONDITIONING �
or o certified copy ihereof�Sec.3800,Lab.C.) . 3 '
O�YNoKN 861—�$���Y IND.ENDEMNITY CE-818(REV.10/81)
Certi4ied copy is here6y furnished. �- U�. COUNTY OF LOS ANGELES BUILDING AND SAFETY ��,�8
� Certified copy is filed wirh the counry bo�lding�nspeo- FOR APPLKANT TO FILL IN BUILDING�
tion depa��ment, � AD�RE55 ��
10-6-87. SANTIAGO A/C �PRINTORTYDEONIY) �p�ALITY �
Date Applicanl ,4. �,��
NO. TVPE OF APPLIANCE OR E�UIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEaRE57 •
COMPENSATION INSURANCE CROSS 57, ,�[Z,
(Thls s�cfion noed not ba complafod I(1ho work involvod 6y ABSORPTION t1N17,6TL1 DISiRICt NO. GROCESS ,gy
Ihe parmil Is for ona h�ndrod dollars(3100)or les:.) �
. I certify that in the performonce of ihe work for which this AIR HANDLING UNIT,CFM � �L,.. �r—
/YL
permit is issued,I shall nof employ ony person in ony manner
so as l0 6ecome subjecl lo the Workeri Compensalion Lows. _ BOILER,BTU AFPROVAlS . pAtE INSCECTOR'S SIGNATURE
Date epplicant COMPRESSOR,6TU ROUGH (�p&� ���
NOTICE TO APPLICANT: If, after making this Certifimte of VENTILATIONSVS7EM � FINaL '�/�J
Exemption, you should 6ecome subjec� to Ihe Workeri
Compensolion provisions of the Lo6ar Code,you mus�iorih- EvneOenT�vE COo�ER � VALIDATION
with comply with such provisions or ihis permit shall be
deemed revoked. �/ Fi�RCE FAU BTU GRAVITY� U .
� LICENSED CONTRACTORS DECLARATION 7 ' � .
I hereby afiirm ihal 1 am licensed under provisions of Chapter 9 HEATER: SUSPENOED UNIT_
'{commencing with Section 7000)of Division 3 of ihe 8usiness �'�`A«
and Professions Code,and my license is in full forte and effecf. . � � � . �'
c3 S a
License N�mber 269496 lic.Class C-2� - �
V
co�rrac�o� SANTIAGO A/Coo�e 10-6-87 O
❑ I am exempt under Sec. Plan chetR fee � �� � 7�2 A � a
8.8P.C.for this reason- ' �
PERMIT ISSUING FEE S �• • • • •8 —
Date:
Si nawre TOTAL FEE p� S�
9 ! • 1 04.75
OWNER-BUIIDER�ECLARATION PIAN CHECK APPLICANT
I hereby offirm ihat I am exempt from the Controctor's license , • � �Q.7 5�
Law for the following reoson(Sec�ion 7031.5, Business and NAnaE �
Professions Code}: � � � Q� �-a 7 •
❑ I, as owner of the property, or my employees with ADORE55
wages as iheir sole compensation,will do fhe work and
�he strocture is not intended or offered for sole(Sec�ion CIiY TEI.NO.
704e,Business and ProfessionsCode). TEIL'' WILLIAM LYON C0.
OWNER
❑ I,as owner of the piope�ly,am exclusively contracting MA`
wi�h licensed mNraclors to consfrucf ihe projeU(Sec- ADORESS 19 CORPORATE PLAZA
tion 7044,Business ond Proiessions CodeJ.
CONSTRUCTION LENDING AGENCY ��T�" NEWPORT BEACH TEI.NO. �
I hereby affirm that Ihere is a construction lending agency fw ' .
�he performance of the work for which this permit is issoed CONTRACfOR '
(Sec.3097,Civ.C.). -- . - .
� ADDRE55 231 W. BLUERIDGE AVE. � � � - � � �� � - - -
lender's Name
°T'` ORANGE 'E�."o. c�gg_1600
� lender's Address 269496
STATE UC.
1 certify that I have read this applica��on ond state Ihot the LICENSE NO. ��C1A55 --� - � �
above iniormation is correct I agree to comply wi�h all County
ordinonces and S�ofe laws relating fo building conslruction,
and hereby au�horize representofives of lhis Counfy to enfer �
' upon the a6ove-meniioned properry for inspettion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE _. . . . .
Ib—G—�'7 .
Signar�re of Appliwni ar Age Data. � � � � � �� �
� • � - • •'INSfEC70R'S NO7ES OWNER-BUILDER DECLARATION
_ , � I hereby offirm that I am e mpt from�the Contmctor's
� � . "� � � � "� � License low for fhe follow'ing reason (Sccfion 703L5,
�.... .. . ." '. ". -..-_'_ .. . .. . ..... .. . .�.. .... .. . - ... ._ .._ _.._ .. .. _. � '� guslness ondP�oiessions Code):Any cify or county which
... � .. , \ - - �equfres a perm�l ro construU,oher,improve,demolish.
- •-� '-- -• � ' " - ' -- �� - � ' � ,cr ropo/r any structurc, prlor fo 11s Issuoncc, also re-
. - � _ _. �.qulres ffio opplimnf for such permit fo(ile a slgned slofe-
� - -� � - -, ' � � - ' ' � ' � meM fhal be!s l�censedpursuontlo iheprovlslons of fhe
�. . ' � Conl�aclors Licnnsc Low(Chapfcr 9(commenc/ng wfth
, ' � ' � ' . ' � " �' � � ' . ' _ ' $etlion 7000)ol Dlvision 3 0�fhe Eusiness ond Proles-
i �, � � 's�ions'Code)or fha�he is exemp�Ihcrelrom and Ihe basis
'�, -. � � � � ' ' ' lor �he alleged�ezempuon.�Any v�ola�ion of Sec�ion
' � _ � _ . 1031.5 by any appficant/or a pe�mit subjects fhe appH-
. . . . � tanf fo a Nvil penofty o�,not more Ifion five hundred
'.... .. . . . _... . .. . . ._ . . _ . �� . dollars(5500).:
�� ' "';, �� ' � � �I,o;owr.er of Ihe properfy will do Ihe work,and -
'-���-" � � � � �� - - the strudure is nor inrended or offcred for sala� .
-___. ._. .. �. - � . . ._ _ _ , � (Sec.7044,6usiness andPro(essions Code: ,TheContrao
,,�;j.; �-� . fo�'s L�cense Law does noi appfy fo an owncr of proprrfy
-- � � � � � who bullds or improves thrreon, and who does such
� _. - work hlmsell provlded Ihat svch lmprovemen�s are not
� - - � � � infended or of(ered(or sale.If,howeve�,Ihc buildinc�o�
, ._ , � Improvement Is sold withln ono year ol comple/ion,the
' - - - � � oviner•buildor wfl!have ihe burden of p�oving ihai he did
- � - - nol build or Improve!or fhe purpose ol eole.)
� - ' ' , . ❑I,as owner of thc properly,am czdusively con-
' ; vocting with licens^d cantr�cters ic tonstruct the projecr
, - � (Sec.704d)Business ond Pro!esslons Cade�The Cmtrvc- "
� � . � ' . �or"s Ucense Law docs nof v,oply to on owncr of propcny
1 j , I f • who 6vilds or Improves fhereon,ond who con��v�ts for
. such profecfs wfth a confrac�or(sJ licensed pursuant�ro
. .. . � � • , .. . . .. .. �. . ihe Confrador'S Licensc Law). '
��ll � • � _ .. . . �. . __ _- .. -
� � I am exempt under Sec.
.. . ., i e . , . . .
- "— �.1 i � � � B&P.C.�for ihis rcoson
..._ ._ ._.._
' � ., � ,, � � . Da1e . .
' � . , , . . . . ,
. _ _ . _ ._. _. -.. . . �-Owner
INSPECTOR'S NOTES ` � �� � �-� - �-'