HomeMy WebLinkAbout1165A WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PERMIT �
I hereby affkm that I have a certificate of consent fo self
insure,or a certificaie of Workers'Compensaiion Insurance, �bA�� HEATING - VENTI�ATING - AIR CONDITIONING
or o certified copy thereof(Sec.3800,Lab.C.) . . . .
CE-B18(REV.10/BI� �
Po�icyt�oKN 861-9����y IND.ENDRMNTTY
� Cerlified copy is hereby furnished. � � �. �'30�� COUNTY OF LOS ANGELE$ BUILDING AND SAFETY
� Certified copy rs filed with the covnty building inspeo- FOR APPLICANT TO FILL IN sui�DiNGn �] e
lion de�Parimenl. ADDRE55 pfC/� �j( �ypl �/'Q
ZO—U—S�T SANTIAGO A/C IPRIMORTVPEONLV) �OCALITY'/) // �
Do�e Applicanf NO. TYPE OF APPLIANCE OR EQUIGMENT FEE �'��`��`�" �',
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST •
COMPENSATION INSURANCE CR055 ST.
(This saction nosd nof ba completed i(Ihe work tnvolved by ABSORPTION UNIT,BTU D�SIRI�T NO. FROCFS$ er
fhe parmtt Is for one hundred dolla�s(5100)or lees.) qiR HANDLING UNIT,CFM n � �r
I certify lhat in the performonce of Ihe work for which ihis „ o"'
permit is issued,I shall nol emp�oy any person in any manner BOiIER,BTu
so as to 6emme svbjecl lo Ihe Workeri Compensotion Laws, nvvaovais . DatE INSFECTOR'S SiGNATURE
Dote oppliconl COMPRESSOR,BTU ROUGH ' .
NOTICE 70 APPIICANT: If, after making this Certificate of VENTIIATION$YSTEM FINAL •�/(.
Exemplion, you should 6ecome subject to the Warkeri
Compensation provisions of the La6or Code,you must forth• EvnPORnTive COO�ER VALIDATION
�wi�h comply wi�h such�provisions or ihis permit sholl be
deemed fevoked. fl1RNACE: FAU_ RAVITY 1�
LICENSED CONTRACTORS DECIARATION . '�/FLOOR eiU -) �D �
I here6y affirm tha�1 am licensed vnder provisions of Chapter 9 HEAiER: SUSPENDED UNIT_
'(commencing with Sec�ion 7000)oi Division 3 of the Business WAu "
and Professions Code,and my license is in full force and effect . . d
269496 r ``�y '�S O
license Number Lic Class C-20 "� ' � V
CL'
eo���ac+or SANTIAGO A�C pQ1e 10-6-87 . 0
❑ I om exempt under Sec. . . _ - V
Plan check fee a
B.BP.C.for this reason� �
PERMIT ISSUING FEE s z
, Dme: � s �1 1 6 S A
Sgnmure � TOTAL FEE /Q ,� . .
OWNER-BUIIDER DECLARATION PLAN CHECK ACPIICANT � {'� � �8
,I hereby affirm�hal I om exempl from the CoNroclar's License , ' . � • � Q�'�5
Low for�he following reason(Section 7031.5, Business ond NAME �
Professions Code): - •
❑ I, as owner of ihe p�operty, or my employees wifh
� A��RE55 • • � �G.7 5�
wages as iheir sole compensation,wJl do the work and � ��T� TEL.NO. ' �', 4—�7
the slructure is rto�intended or of(ered for sole(Section
7044,Business and Professions Code). � �
OWNER
❑ I,os owner of the proper�y,am exclusively contracting
wiih litensed con�ractors ro mnstroct Ihe project(Sec- DDee55 19 -CORPORATE PLAZA .
tion 7044,Business and Pwfessions CodeJ. .
GONSTRUCTION LENDING AGENCY �ijY�� NEWPORT BGACH TEL.NO.�-� -- - " . , .
I here6y offirm that there is o construction lend�ng agency for � � .
the performance of the work for which�his permit is issued - CONiaaCiOa - � � '
(Sec.3097.Civ.C:). - -. . . . . ..
nooaess 231 W. BLU�RIDGE AVE.
Lender's Name
. . CI7Y TEI.NO. . .__ . . .
lender's Address �
I certify that I hove.eod this appiication and state that the �ICENSE Nc269496 C n55 C-20 , _ .. . . . .'
above information is mrrect.I agree to comply wiih all County '
ordinonces and State laws relaling lo boilding construction, � .__ _ . _ . __ . . ,
and here6y aulhorize representatives of this Counfy to enter . � �
�pon the above-meni�oned property for inspeUion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Y /G'�'S �
ignoiure of Applicon�or Aqen Daie � • .
,. .. , ..
� , � •• - • � - � INS!'ECTOP.'S NOTES , OWNER-BUILOER DECLARATION
-�- � I hereby oHirm�ihat�l�am exempl from thc Controcior's
� - � �� � �� -'" -'� ' Licrnse Low for the followinq reason (Secflon 7031.5.
..v...___._'_..._.�.___.. _._._..__.... _ _ _. .. . . .. . __ .............. . . .__.._._.. _._._.. . .-�:.'_-.'...'.� BuslnessondfrofesslonsCode):AnyUtyorcounfywhich
_ � � � � � � � - �� �� _ requires o permif ta c nsrruct,cl�cr,Improve.demol�sh,
��. � - �'.� ' • ° .
' ' --�'-� '- - ' "-- " - ' 1 � �� ' ' ' � - � or repafr any strucfure, prlor lo Its fssuonce, olso�e-
� � , ,_ ��, „ . � ` � , , � _ qulres ihe opp7ican}!or such permit b ftle a signed slate�
- - -�-� "-��"'� ""- " � ' � " . . ' � ment ihof he Is Iicensed pursuon�to fhc provBions of tho
� � � . , , � Confrocfori Lken'se Lavi(Chapter 9(commenUng wHh
' '... . . �'. .'.. . �
"-"""�""- ' '' "' �-- " �'� "' ' '�� ' ' ' � Section 7000)ol Ofvisfon 3 0(fhe.Bvsiness and Pro�ez�
� � � ' �sions Codef or Ihol he is exempi ihere7rom and 1fio bosis
� � . � ' _ � � . - � � ' �� lor fhe olleged eaempfion. Any viofolion of Setfion
`__'_.__ __ .._... _ __. . _ . �__ � ._ .� i � . 7031:5 by ony applicanf/or o permit subjeds fhc oppli-
. � �� - . , , � � ' , canf!o a civll penally ol nof more thon live hundred
'_ _ . . . .._.__. . . . . . _ - � rs(SSOD).:
dolla
j � �� � � � �� � � - � ❑I,cs owner of the property will do the work,ond
. � � � . �- - - - �. �, . _ , . the slructure is nol intrnded or offered for sale.�
'-----�--- ----�-'�--� --=- --- - -- - � � - � -(Sec.7044,BusinessandPro/esslonsCode:�_iheCoNroc-
p'-,:�,;',i'� , �tor's Lkense!aw does not oppfy�o an�ovmer ol property
-- "- � " �� - � � � who bWlds�or�7mproves lhareon, pnd who does sucb
, . . - � . . work himseN provided Ihat eucb lmarovements ore not
� �� � -- � � � � � infendedorofferedforsole.if,"howevet.thebuifdingor
, . . _ . . �� improvemen/is sold wiihin one yecr of<omplefion,�fhc
� � �� � owner-bullder wfll havo fbe burden o(prov)ng ihaf he drd
. _ . � � not bufld or Improvr for fho purpose oi sale.) � �
� - - ' ❑�,os owner of the properly,am exclusively con-
�� ' - tracting with licensed�mntractors to con;truc�the projec�
, , � �- - -- �� � (Sec.701a)Business and Professlons Codc:7hc CoMrac-
� . � ' for i Litense Low does nol appfy�o on�owner af property
- � - who 6utlds or lmproves thereon,and who canfroc�s lor
� - � � � � � su[h Pfojecfs Wffh a contracior(sJ licensed purseont to
. ' - � thc Contracfor's Llccrtse LawJ: '
-. .. r r �
• �5v . �. . . , ... _ . . . . . _._ . ._ . _.. .. ._ . . . _ .
- �� � ' � � I am ezempt�under Sec�' -
,.'`,71 � I
— , � � � B&P.C.for this reason �
—11 , !;• 1
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- - - - . � �ate �
. ;. _ -- _. _ _. : : . ;:����' . .,� .. ��_ .. ' Owner , .
. i . .. . . . ... . � - .. � .
INSPECTOR'S NOTES ' _ _ - � - -'`�
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