HomeMy WebLinkAbout1170A (5) WORKERS'COMPENSATION DECLARATION � APPLICATION FOR PGRIY�IT �
I hereby aff'cm ihoi I have a tertificate of consent to self
insure,or a certifimre of Warkers'Compensation Insorance, ��3�� HEATING - YENTILATING - AIR CONDITIONING �
or a cert�fied copy thereof(Sec.3800,Lab.C.) CE-818(REV.10/61) � - 3d"
voticyNoKN 86I—�$��y IND.ENDEMN?TY
❑ Cenified copy is here6y fum�shed. v COUNTY OF LOS ANGELES BUILDING AND SAFETY
� CertHied mpy Is iiled wiih the munry bu�lding inspec- FOR APPLICANT TO FILL IN BUILDING!1�
tion deparlmenL (PRWT OR TYVE ONLY) P.DDRE55 pY.•7� � �� � q—
Daie 14-6-87 APPlicant SANTIAGO A/C: iocauTr u���l ��
� NO. TYPE OF ApPIIANCE OR EOUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEARE57 tl
' COMPENSATION INSURANCE � CROSS ST. !/L,(.�r
(This section noad not 6e compl�tad 1(tha work Invoived by . ABSORPTION UNI7,etU piSlRiCi NO. PROCESSE er
ihv pormif Is for one hundrod dallors(SI00)or less.) qip HANDUNG UNIT,CFM V(/"�
I certify that in Ihe performance of 1he work for which this O� �
permit is issued,I shall not employ any person in ony manner gOItER,BTU
so as fo become subje[t to the Workers'Compensalion laws. nvpaovnl5 DniE INSGECTOR'S SIGNqTURE
Dafe opplitanl - COMPRESSOR,BTU ROUGH V � �
NOTICE TO APPLICANT: li, o4ter making fhis Certi4icale of VENTILATIONSYSTEM FINAL �� � L�
Exempiion, you should betome subjecr to the Workeri
Compenso��on provisions of the Lpbor Code,you most iorth- EVAPORATIVE COOLER VALIDAT�ON
wilh compiy with soch provisions or ihis permit shall be �
deemed revoked. FURNACE: FAU RAVITY
- � LICENSED CONTRACTORS DECLARATION FLOOR BTU r � �
- 1 hereby offirm that I am I�censed vnder provisions of Chapter 9- SUSPENDE� UNIT_
HEATER: WA��
�(tommencing with Setlion 7000)of Division 3 of Ihe Business �
and Professions Code,and my license is in full force and effect. n/ J . a
� O
License Number o��C��� lic Class E z�e � � � -� , V
Contmaor_SANTTA(:(1 A/!`Date 1l1����_R7 � � �
O
�
❑ I am exempi under Sec. . uVi
Plan check fee N
e.BP.C.lor this reason PERMIT ISSUING FEE S /0 O �� 1 7 O A �
Date:
Sgnmure TOTAL FEE Q JS tJ• • • • •8
OWNER-BUIIDER DECIARATION PInN CHECK APPUCqNT , � I • � O G.I Jr
I hereby offirm that I am eaempt from the CoMractor's License �
Law for the(ollowing reason(Section 7031.5, Business and NAME , , • • � Q(�7��
Professions CodeJ: �
' ❑ I, as owner of fhe pioperty, or my employees wilh AD�RESS �Q� (!_�,'�
wages as�heir sole compensatian,will do ihe work and ��iv TEi.NO.
�the structure is not iniended or o{fered for sale(Sedion '
7044,Business and Proiessions Code). � � � �
owNea THE WILLIAM LYON C0.
❑ I,as ow�er oi the properly,am ez[lusively controcting
with I�censed mNractors ta construcl the projeU(Sec- DDRESS 1 g CORPOR61`r� PLE�ZA
tion 7044,.8usiness and Professions Code). -
. CONSTRUCTION LENDING AGENCY CITY NEWPORT BEACH TEL NO. � �
I hereby aifirm thot Ihere is a construdion lending agency for �
ihe performance of Ihe work for whith�his permit is issued � CON7RACTOR SANTIAGO A/C - � ��
(Sec.3097.Civ.C.). . . . -. . .
ADDRESS 2 1 . BLUERIDGE AV�. � � - � � � - � -- � - �
lender's Name �
cirr ORANG� TE�.No. 998-1600
Lender's Address
I certify that I have read thrs oppl�cai�on and siate ihar the ucinEise Na269496 . ��ASS _C—`Z� _ .. .__ . _ ._
above iniorma�lon is correcr.I ogree ro comply with all Couny , .
ordinances and State laws reloting to building tonslrvction, _
• and herehy authorize represenlatives of ihis Covnry lo enter � - � - � . � - � . � � - .
�pon the obove-mentioned proper�y for inspeUion p�rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
��ti� �C�—(�`��] . . . . . . ,. _ .
gnaWre of ApplicaN or Agen Dote . .
� - � • � ° INsrEcro�'s raoies OWNEP,-QUILDER DECLARATION
� - ���.1 hereby affirm that I am'exempt from ihe ContraCtor's
. - � ' � � -' - . License Law for Ih� Followinc� reason (Sedion 703L5,
... _---_.____.__.._ ._.__..._ ...__ ...__ .._. .__.. . __ . . . ... .. . _...._. .. . ' . �' ' BuslnessandProlesvo�sCodel:Anvc�ryorcounrywhicF
{ ' . . . - � � � �requires o permlt m cons�ruc�,alter,Improve.�demolish,
. �--�� -� � � -� � ��- - �-' .� � �-� - ' � - � or mpa/r any strucfure, prlor to Rs lssuoncc, olso rc-
' �� � �- � � . :qulres�lheopplimnlforsuchpermltlo/tleas�gnodsfale-
- � - � � �� � - �- � � ment fhat he Is licensed pursuaN to thc provlstons o/fhe
. � ,�� � . Confrocror':Lrcen:e Cow(Choprer 9(rommencrng wr�h
�''-"' � -' � �� � -"- �" ' �� � . . ' ' '� Seclion 7000)oi3Oivizion 3 0(1he Business and.Prolos-
� sions Code)or ihof he is exemPf{herelrom and IF�e basis
i ` ' I\ � ' � . � lar Ihe olleged c mp7ia . f�ny�violollon o/Secfion
xe n
� 703L5 by ony 6ppliconf!or a permit subfecfs Ihe oppli-
� � ,. , �, , . - ,. , . . : _.- . � � . con�fo a dvlf-pen?Ity oF nof morc fhon fivc hundred
,. ....-_ .__ _ .._ . _. . . .. . . � .dollors(SS00J.: . . .
, . '- ,, ' � - . . - � ' � �I,os owner of the property will do Ihe work,ond
,i; ;
I--� � �-��� - ' � � � . ' , � the struciure�is not intended or offcred for sale_-� �
.-... _ ._. ._. .� . . . ._ . ._ . . � : (Sec.7044,6ustness and Pro�essfons Codc The Controc-
� � . , �for's lkense Law doet not opply lo an owner of praperty
��-� -� -� � ' - - �. who bulids or improves lhereon, and who does,such
_ � � � � � work himself provided tha�such Improvemenh ore no�
- � - ' � � in�ended or oflerod ior sole:H,however,fhe buifding or
� ; . _ . � � 7mprovemenf is so/d wifhin one year ol complellon.Ihe
. � � - - - � � owner-6Wlderwilfhave16e6urdenofproNng7hothedid
.. � , � �naf build or improve for fhe purpose ol sale.J' �
, � - � � � � 0 I,os owner of the property,am exclusively con-
, � ttocting with licensed coMroctors ro construU the pro;ect
- � ($ec.7044)Ausinoss and Prolessions Code:ihc CoN�oo
� � ��-tor's Llcense Low docs no�apply lo an ownef of properfy
� . -- � -' who bulfds or Improves Ihereon,and who cantrecls(or
. �. � ' - ' '� � � wch projeds wilh c conlracfor(s)lirensed pursuonf to
!i(1� I � �- : � � fhe Contractar's'license Caw;. ' � ' ' �
. . , . - . . . - . . . . � . _
[., . . �.
.. . .,`..) ( • 1 . . . . . . I am exemp!under Soc. .
_ .. � .,�i i . . . . �. . . � ,�. -. -; � , . .
- � . - B&P.C.for this reason
, ,—,� rni ; � � .
, �
_. _ _ - - -.. _ .
- � � � � - � Datc ' � . . . �
' -- -— Owner,
INSPECTOR'SNOTES - � � - ��- � - �� - �
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