HomeMy WebLinkAbout1168A (5) � WORKERS'COMPENSATION DECIARATION �
I hereby aitirm tha�I have a certificate of consen�Yo se�f . , � APPLICATION FOR .PERMIT
insure,or a cerfificale of Workers'Compensotion i�5,,.o��e, . �bA�� -� - - HEATING - VENiIIATING - AIR CONDIiIONING
or a certiiied copy fhereof(Sec.3800,Lab.C�) -�.g18(REV.l0iB1)
Policy NoKN Seil—9�$�,�„y IND.ENDEMNITY ' COUNTY OF LOS ANGELES � � � BUILDING AND SAFETY 3 D
� Cenified copy is hereby furnished ��'30�� � .
� Ceriified topy is filed with 1he county buildfng Inspeo- FOR APPLICANT TO FILL W � 6UilDING b
�tion depariment. ADDRE55 p70)�
. (PRINT OR TYPE ONLY)
• Dare 10-6-57 Applicant SANTTAGn A�C iocsuTr '
NO. TVPE OF A7PlIANCE OR EOUIPMENT FEE � .
CERTIF�CATE OF EXEMPT�ON FROM WORKERS' � NEAREST •
COMPENSATION INSURANCE CROSS Si.P�
(This s�ction aaed not be tomplafed if the work Involved by ABSORP110N uNIT,BTU oisruicr No. � iROCE53 ar
the permit B for one hundnd dollars�S1DOJ 0�IeSs.) - qIR HANDUNG UNIT,CFM p� � `��(
I certity that in the performance of the work for which this �(f—" ,
� permit is issued,I sholl not employ any person in ony manner � BOILER,BTU
so os to betome sobjeU to�he Workers'Compensation laws. ncvaOvniS DATE INSPECTOR'S SIGNAIORE
Date opplicant COMPRESSOR,BTU ROUGH
NOTICE TO APPLICANT: tf, ofter making this Certificate of VENTI�aTION SYSTEM FINAL �'�. �/� ,
Exemption, you should become su6ject �o the Wo�ked .
Compensaiion provisions of the Labor Code,you musf forlh- EVAPORA7IVE COOLER VALIDATION
wi�h comply,with soth provisions or Ihis permit shall be
deemed�evOked. � FURNACE: FAU G AVITY
LICENSED CONTRACTORS DECLARATION � FtOOR B7U 0'Z)
I hereby affirm that I am licensed under provisions of Chapter 9 HEAiER: SUSPENDED UNIT_ �
'(commencing wi�h Section 700D)of Division 3 of Ihe Business WA«
and Professions Code,and my license is in full lorce and effect �/ • � � - �
269496 � s
0
License Num6er Lic.Closs C-2� " - � , V
Contm[br Dale � � ' �
�e Nm r-A�9—A-�G �l � 87 �
� u
I am exemp��nder Sec. w
. Plan check fee y
B.&P.C.for�his reason PERMIT ISSUING fEE S / (� • �1 1 6 8 F Z
Dote:
Signature TOTAL FEE p �• •.• • •8
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I • � �Q,7 5
I hereby at(irm�hat I am exempl from Ihe ConiraUor's License
Law for the following reason�Section 7031.5,Business and NAME , • � � Q�;,7 F�
� Professions Code): � �
❑ I, as owner of the prpperty, or my employees with � ADDRE55 . . I Q� G��a'J
wages as their sole compensation,will do the work ond CITY TEI.NO. �
ihe shuclure is not intended or offered for sale(Seclion .
7044,Business and Professions CodeJ. . ,
❑ I,asownerofthe � owNER THE WILLIAM LYON C0. • _ �
p�operfy,om exclusively contracting
wifh licensed coniractors to construct the projecf�Sec- qDDRE55 19 C'OF;.PORATE PLAZA
- tion 7044,Business and Professions Code).
CONSTRl1CTION LENDING AGENCY � CiTY � NEWPORT BEACH TEI.NO. � � � � "-��
I hereby affirm Ihal ihere is a construction lending agency for '
the performance of Ihe work for which this permit is issued CONiRACTOR SANTIAGO A��,' ►_
� (Sec.3097.Civ.C.j. . ... ... .. . . - - - - .
� ADDRESS .� E VE.
�ender's Name
crcv TEi.No._ 998-1600 1 .
Lender's Address .
I cerlify�hat I have read rhis application and stote that the LICENSE Ne269496 �Lqss �•'—`�� � -.. �� �- �-� -_ � �_ �
above iniormotion is correct.I agree to tomply wilh oll Counly .
ordinances and State laws rela�ing to bu�lding mnstruction, . . .�_ ,,._ _ '
and hereby aulhorize representatives of this County�o enler � � . �
upon rhe above-meniioned property for inspec�ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
/o-G-�'�
ignot�re of Appliwm or A� Dore . � . . . . .. .. . ...�. �.. � . . . .
� - - • - 1hSRECTOR'S NOT[S ' OV�JNER-[iUILDER DECLARATION '
� . . ' ' - �I hereby affirm thm I om exempt irom'the Controctor's
� ��- � � -' � ' ' - License law for �he following reason (Scctivn 703L5,
,. .___... . �......_..___.. .. __ ......_.. . ... ....._ .. _._.... . ._ _.... ..._._. ._. _ . -� ....' . Duslness andPro(essions Code):Anyciryorcounty-whtch
� . , , � � � � � requtres a perm7/fo construct,dltei,��imp�ove,demolish,
--- " - � ' � � - -'� � ' � - ' - � - � or repafr any struUure, prlor lo Ifs�issuance, olso re-
. , � � ' � - � __,:_ .qulros ihe appYcant for such permu ro Hle a s�gned stoto-
--��� -- ----�—- �' � �� �� � � ` - � � � � - ' menl tha�he is flcensed p�rsuaN fo fhe provislans of the
— . � � � . � Conlracfor's�Lkensv Law(Chapfer 9�(commencing wlth
� '.� •. �� � .',.- .
' ""' "�'�- � ' � �� - -� ' '� ���� � � " I Secllon 7000J o�,Division 3 0(Ihe Buslness and Pro/ez-
: � � sions Codc)o�ihal he is erempf Ihcrclrom�and the 6asis
' � " � � , � � . . � � �for fhe alleged exempfion. Any viofa�fon o( $ec�lon
. . _. . . . . . _.... _ _ . � . , 703).5 by any applicant ior c permif subjetls 1hc'oppli-
, . . ' � . . �� � � � con/to a rivll�penahy of no�more,fhon/ivc hundred
4_ .._-_ _ .____ .. _ .. . _. . _. . . " - -—. -' '. dollars(5500).� . .
'� i�,� . , , ' ' � - � .- . - � � ❑I,os owner of�he propmty will do the wark,ond
� �
�' ��--- �--�- ----�-�- � ' -�-� �-����� � -- �- - --the structure is not infended or o!fered for sale.�
� ... .. __._. . -_ .. _ . . . �. . . .. . ':.-� �� � . . . � � �..(Sec.��7044.Busines�s andP�olesiions Code: -ihe Confrac-
� � . . � lor's License Law,does not opply fo an owner ol property
-" - -"�- " � � - � � �� who 6uifds or Jmproves lhereon,�ond who does such
�, , � . �� � work hfmsel!provided Ifiot such lmprovemenls are nol
� � � � � �� lntended or oflered lor sale.1(,however,the huilding or
. � � � Improvemenf is sold withln one year of complefion.the
, '� - -�- - � � owner-6ullder will have fbe bvrden ol proving thot be did
; � nol bulld or lmprove lor fhe purposo o/eale.) -
\ •
, - ❑I,as owner of fhe.propeny,om exclusively con-
, . � " � . - —� trocting with litensed mntracton Fo mns�ruct Ihe project
(Sec.7044)6uslness and Prolessions Code�7he Confroc-
� � ' , for's L(cense Lawdoes nof opply�fo an owncr ol properfy
� who buifds or Improves fhereon,ond who conlracts(or
� ' � � ' ' such projec}s wlth a cantrootor(s)licensed pursu6nl lo
,,� j �. �� - � � � - - - 1hc Confracfori ilcrnsc Law). � - � �
� . • n � , - . � ._ . . .. . . . . . . . . . . . . _
_ - _. _ _ . .... .. . ._ _ . _.__ . .
-� � ��J � • � � �� � � I am exempt vnder Sec. '
. . .. �. �. r �• 6 -- ' B E P.C.for fh�is reoson �� .. . . .
—;; ( ') 1
. � ----- - . Date � -
� '. .. ..�.1. . . . ... . � ` Owner . . .' .
INSPECTOR'S NOTES