HomeMy WebLinkAbout1171A WORKERS'COMPENSATIONDECLARATION qpp��CATION FOR PERMIT �
I hereby affi.m that I have a certificate af cansent to self
��g��e,or a certificale of Workeri camPe�Sar�o�i�5„�a��e, HEATING - VENTILATING - AIR CONDITIONING
or o certified copy thereof(Sec.3800,lab.C.) � 76A36aC
KN 861—��,� IND.ENDEMPIITY CE•818(REV.l0i81) ?2
P❑ol�icy No. Y J� .
Certified topy is hereby furnished. U� COUNTYOF LOS ANGELES BUILDING AND SAFETY
� Cer�ified copy is filed with the county buildi�g inspec- FOR APPLICANT TO FILL IN BUILDING
tion deparlmenl. (PRINT OR TYPE ONLY) P.DDRE55 �Q ��� —
Date 1 n_F'i_R7 Applicom SANTTAGCI A/C IOCAUTY �����1�,
NO. TVPE OF A7PLIANCE OR EQUIGMENT FEE
� CERTIFICATE OF EXEMPTION FROM WORKERS' � NEnREST
COMPENSATION INSURANCE CRO55 ST. e,v �
(This sxfion naod not b�eompletod H th�work involvad by ABSORPTION UNIT,87U oisraia No. raocess ar
1h�permk is for oao h�adnd dollars(5100)or Io�i.) 'a �'n (�r
I certify Ihat in ihe performonce of Ihe work for which this AIR HANDUNG UNIT,CFM
permil is iss�ed,I sholl nol employ any person in any manner
so os to 6ecome s�6jeci to the Workers'CompenSa�iOn Laws. BOILER,BTU APPROVALS DAiE INSPEGIOR'S SIGNATURE
Pp1e APP�ICan' . COMPRESSOR,BTU ROUGH �Z� L���
NOTICE TO APPLICANT: If, ai�er making this Cenifimte oi VENTIIATION SVSTEM FINAL �j%���
Exemp�ion, yov should become subjecr to the Workers'
Compensation provisions of�he Labor Code,you mo51(Orlh- EVAFORATIVE COOLER VALIDATION
with comply with s�ch provisions or ihis permi� shail be .
deemed revoked.. �[ FURNACE: FAU VITY
IICENSED CONTRACTORS DECIARATION / FLOOR BTU O
1 hereby affirm fhat I am li[ensed under provisions of Chopler 9 HEATER: SUSPENDED UNIT_ -
`(tommencing wiih$eclion 7000)of Division 3 of Ihe Business WA«
ond Professions Code,and my license is in(oll force and effect.- � • . p},
269496 `; 5 S o
. License Number Lic.Class C-2n - ► V
�
Cantractar .0 ANT T 6(7!1 A/f'Date 1(1�.�T,_5:7 � ' - �
� u
I am exempt undcr Sec. �
Plan check fee °�
B.&P.C.for this reoson � y
PERMIT ISSUING FEE S /p �1 1 7.1 A z
Dale:
� TOTAL FEE ],.5 #• • • •8
Signature �
OWNER-BU�LDER DECLARATION � PLa.N CHECK n7PUCAnIi . I • � O ll,7 S
I hereby affirm thot I am exempl from tbe Conlractor'S License ,
Law for Ihe iollowin9 reason(Seciion 7031.5, Business�and NAME � � • • � ��'�5�
Professions Code): � �
❑ I, as owner of the properly, or my employees with AOORE55 . I O,� 4�8 7
� woges as Iheir sole compensation,will do the work and CITY TEL.NO.
the strocture is nat inlended or offered for sale(Seclion "
7044,eusinessandProfessionsCode). TEIE WILLIAM LYON C0.
OWNER
❑ I,as owner of ihe properly,pm exclusively contracting
with licensed[ontrpClors t0 conslru[t Ihe projecf(SeC- DOftE55 19 CORPORATE PLAZA
tion 7044,B�siness and Professions Code).
CONSTRUCTION IENDING AGENCY - OTv NEWPORT BEACH re�.No. �
I hereby affirm Ihot there is o canstruction lending ogenty for � �
the performance oi fhe work for which this permit is issued CONTRACTOR SANTIAGO A/C �
(Sec.3097,Civ.C.J. - -- . . . . .
A�DRESS 231 W. BLUERIDGE AVE. � - - - '
Lender's Name
. CITY ORANGE . TE�."o. ggg_1600 -� � � � - -
Lender's Address
I certif thai I have reod this o licot�on ond state that Ihe sinie liC.
y pp uceNseNo269496 CLA55 C—z0
above informa�ion is correct.I agree to comply with all County .
ordinances and State laws relaiing to building tonstruction, _ _ , , _ . _, . _
and hereby aothorize represeNatives of this County fo enler - .
upon�he above-mentioned properry for inspeU�on purposes. _ SEE REVERSE FOR E%PLANATORY LANGVAGE . - . ' -
� /O—G—��
Signa��re of Appliconr or Ag i ��e
� ' ' - � INSrEGiOR'S NO7ES OWNER-GUILDER DECLARATION
. - � � �I hereby atfirm tbcl I om exempt from ihe Contraclor's
�� ��'� ' � � � ' ' " License Law for fhe followin�j,reason (Secfion 7031.5,
i_... . .__. _...._...__.. .._... . .. ._. . . .... . __... .. ... . .....- ... .... . , .: . . . ,_."� - BuslnessandProlesslonsCodeJ:Anycifyorcounlywhich
- ', � �_ , - - �equires a permif fo conslrucf,olfer,Improve,demolish,
� � � �"� ' � -,� -� ' - . � or repai�any sfru[ture, prlor to ifs Issuanrn, olso re-
, • � ,qulres fhe applicoN(o�suth permif to fllc a si�ned sta�e-
� - -- ��-��, � � , - � -� � � � � ' � ment iho/he Is Iftensed pursuanf to�he provBions of 1fic
' � � ' , , Confrotlor's Llcenso Law(Choptcr S(commancing wifh
�� � � � � � � � �- � ���� ���� ' -� ' � Section 7000f of Divizion 7 0/fhe Business ond Profes-
' � , slons Codef or fhat he 7s excmpt Iherefrom and the bosis
'� � �• . ' � � �- -� (or fhe alfegcd exnmp�ian. Any�violofion of SecNon
_ _ _. _._. _. ... . . _ _ � �� , _�7031.5 6y eny appfimnf lor o permit subjecfs 16c appli-
� � � � . � - - - - - � , cant fo a civil penolry of nol more �han five hvndred
�_ --.. _ : doira.s�ssoo�.:
,'•��' '--��.: �4! � � _. . _... ... ;� � . '' • ❑I,as owner of thn proporty will do ihe work,and
� " � , ; . , -�Ihe strudure is no�iNendcd or offercd for so�e:: �
� - - - -- ��-- � � - - -- - - � � � � (Set.7044.Business andProfessions Code: The Conlrao
' ' '. ' ; � . , for's Utense!aw does not oppfy}o on oivncr ol property
- � , who bulfds or improves thereon, and who does such
' . �. - . , work himseB provided�ha1 such Improvemenfs are nof
� � � � in/ended or offered lor sale.I/.however,Ihe 6uilding or
' - - - � . _ . improvemenl Is sold wl�hin one y�or ol�compfoHon,�fhe
� - - owncrv6uilderwlfl hevc fhc 6urden ol proving fhat hc did
. � nof bui7d or improvc for fhc purpase ol sofc.) �
_ , �
- � � �� ❑I,os owncr af the properly,am exdusively con-
' � � ' � - tro.ting with licenmed contro:fors to constr�ct th�pr'oject
- � -- - (Sec.7044)8usiness and Pro�essions Code:The Contrac-
, � �-�to/s License Caw does no/apply to an owne�ol properfy
� ' , _ � - - - who bWlds or�mproves ihcrean,and who canlroc�s(or
' � - such projects wlfh a confroclor(s)licensed pursoanr to
°, � ;,' � � _ the Con�ractor's uce�se'LaN:).
. , . • . :� , _ .
��'C;J � . � � � � � I am exempt�under Sec.
- ' . � • • . 8 8 p,C.for Ihis reason �
\_-AIOI
. - . ---I - -- , . . , . Dare � ' �
� !..,: . �. ". . . . i . � � .
.. .. _ ._. . .. . .. . .. _. . � Owner
INSPECTOR'S NOTES -