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Home My WebLink About1169A WORKERS'COMPENSATIONDECLARATION _ APPLICATION FOR PERMIT � I hereby affirm tha�I have a certifica�e af consen�to self , . insvre,or o cerlifimre of Workeri Compensation Insvrance, �bA3aac � - • HEATING - VENTII.ATING - AIR CONDITIONING 3/ or a certified copy thereof(Sec.3800,tab.C.� CE•818(REV.IOi81) ��' �' � - � � � �- ��, ��YNoKN 561-4��,�„y IND.ENDEMNITY Certified copy is hereby furnished. ��.0 COUNTY OF LOS ANGELES BUILDING AND SAFETY � Certified mpy is filed with the county building inspeo- FQR APPLICANT TO FILL IN BUItDING � � lion deparfinenL (PRINT OR TVPE ONIY� ADDRE55 p�Q�� oaie 10-6-87 Applicant SANTIAGO A/C �ocnurv ' � NO. TVPE OF APPLIANCE OR EOUIPMEM � FEE `� � CERTIFICATE OF EXEMPTION FROM WORKERS' NEaeEST . COMPENSATION INSURANCE Ca0.55 ST. (This sacfion na�d not bo tomplalud if�he work involvad by ABSORPTION UNIT,BTU oiStaiCt Ho. �, vaocc55 er th�pormit is for one hundred dollan(31D0)or lass.) � pIR HANDLING UNIT,CFM p— �'�'w� 1 certify Ihat in ihe performonce of ihe work.for which ihis � � permit is issued,I sholl nai employ any person in any monner BOILER,BTU �so as to become subject to the Workers'Compensarion lows. aPveovais DAiE INSCEQOR'S SIGNAiURE � Date opplimnl fOMPRESSOR,BTU ROUGH ' � � NOTICE TO APPLICANT: If, afler moking fhis Cer�ifica�e of VENTIIATION S�STEM . ' FINAL � � �� Exemption, yau shauld become subjecl to Ihe Workeri Compensotion provisions of the labor Code,you must forlh- EVA70RATIVE COOIER � VALIDATION winc �omply wi�h such provisions or this permit sholl be � � deemed revoked. � � `' FURNACF. FAU GRAVITY � LICENSED CONTRACiORS DECLARATION �7" FLOOR BTU ' 1 hereby affirm that 1 am licensed onder provisions of Chopter 9 SuSaENDEo UNii_ �(commencing with Settion 7000)of Division 3 of ihe Business HEATER: WA�� . ond Professions Code,and my license is in full lorce and effecl. �j _ . � ' y . �" C.7 U � License Nomber -•6A��E �Lic.Class �-'-7n - �V eontroc�or SANTIAGO A/C Date 10-6-87 , I O ❑ �I am exempl onder$ec . . w s.av.c.fo��h�s reoso� Plan check fee < « 1169A � PERMIT ISSUING FEE S /O ` ' �. . . . ,g = Date: Sgnature TOTAL FEE D `f 3 OWNER-BUIIDER DECIARATION 7LAN CHECK AGPLICANT . � • � O a'7`5 I hereby affirm fhat I am exempl from the Confratlor's license , ► - . � � e � O�'�5` � Law for Ihe following reason(Seclion 7031.5,Business and NAME " ProfessionsCode): - �- � ❑ I, as owner of the property, or my employees wilh ADDRE55 �, � O•� 4—S 7 wages os�heir sole tompensation,will do rhe work and ' the struUure is nof infended or offered(or sale(Se:lion O7Y TEt.NO. , 7044,Business und Pwfessions Code). - � . owNea TfiE WILLIAM LYON C0. ❑ I,as owner of the property,om exclusively contraUing , , , w�+h licensed coni�acto�s to constroct+he project(Sec• DDRE55 19 CORPORATE PLAZA � tion 7044,Business and Professions CodeJ. �. CONSTRUCTION LEN�ING AGENCY ��TY NEWPORT BEACH TE�.NO. ' � I hereby affirm thallhere is a construction lending ogency ior , . � ihe performance of the work for which this permit is issued COMRACTOR ANTIAG A C � � (Sec 3097,Civ.C.). .. . .- . . - ADDRE55 231 W. BLUERIDGE AVE.� � ' - � . �� Lende�'s Nome c�rr ORANGE rE�.No. gg8-1600 Lender's Address I rertif ihat I have read this a licotion and stafe that fhe S7ATE UG ; . y pp uceNse NQ269496 QA55 � �,'—`Z� abave infarmation is correcl.I agree to tomply with oll Counfy . ordinances and State lows relaiing to building construtlion, . � ond hereby authorize represemalives of this County to enier � � • � � � upon the above-mentioned praperry for inspettion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �_�� /o—G—B� Signoture of Applicanr or Ageni Da�e . � . � � ' - ' INSI"ECTOR'S NO7E5 OWNER-ElUILDER DECLA�'ATION , ,- . . .. . ' 1 horeby`offirm tho�I om exempt from Ihe Coniroctor's � - License Law for the following rcason ($eUion 703L5. : ._.......___.�_. . .._. . . . . �, . _ '•� :�. . _ ,, .___. . _ _.. ..__ . .. . _ _ . . . . . - � ' Business and Prolesslons Code):Any Uty or counfy which _ ' �. , ,, � . - � requlms o permif to mnstrucl.olMr,lmprove,demolish. '-" "-�'-�-' � � � - - " - � ' � � or repair ony slruclure,prror fo ils issvonce, also re . �� , '� __ , qulres the opplicont for such permll fo/ife a slgned stole- -� - -- - - - ' . ' - � ment Ihol ho le Ilaensedpursucnf to�Feprovlsions ol fhe ' � . � � � ' � . � Canfrocfo'r's.Llcense Law(Cfiopter 4(commencing wHh � ��-�- -� " � '� � "' ' "- '� � $edion 7000)o�Divislon 3 0(fhe Ouslness ond Ptoles� � , ' . � � � , � sions CodeJ or Ihal he is exemp}fherefrom ond fhe basis , �.;.� .� + ' " � lor Ihc�oileged exempiian. Any viol6tion of Sectlon i.—.. - -._- .-- . _ . .. . _. , 70J1.5 by any applimnt for a permit subjetls}he oppd� . . . - canf}o a dvif ponally o)not more ihan llve hundred , --- - -- - � - ' dollars(5500).; � '_ .___..'..- ,1 1 _ J� . . . - - � � ❑I,as owner of Ihe property will do ihe work,and � , � . , ' -Ihe slructure�is nm inrend�d ar offcred for sole. �- --�- � -- - � �- - - - - � -• � � � .(Sec.7044,Business and Professions Code:"The Conlroo , . � . � � . �or's Lkense Law does not opply fo an owner of property ��- - - ' ' , � _ who builds or improves Ihereon,.artd.who does sacb � , . work hlmself provided thm such ImprommeNs are not � - � � � iNended or offered for sote.If,however.the building or , , . , Improvemenl is sold wllhln one year of cvmplvfion,Iho � � � owner-boilder wllf havo ihe burden of proving ihof he did . � . . nof bulld or Improve for fhe purpose af sale.) , � � - �� ❑�I,as owner of ihe properly,am exclusively mn- � . - �trocting with hcenscd c6ntractors to construct Ihc projecf � � '. - - (Sec.704d)6usinoss and Pro(essions Code:7he Confror � . � � � � � for's llcensc Cow iJocs'nat apply fo an awner ol property , - who bullds or fmproves.thereon,ond who eonlrocts(or ' ., ' � � �- �� - �� sucF projecfs wilb a contratfor(5)licensed pursuvn!to � . ' � - 1hc Conlrac�or's Licrosc Lo�++J. � � � { � � . . .� , .. _ . _ .._ . ... � _ � � ' I am exertipl under Sec. , �. ��J I . B&P.C.for this reason�� ' � . . . � . Dote ' � , . . . ..Owner � � - � INSPEC70R'S NOTES � - -