HomeMy WebLinkAbout1166A (5) WORKERS'COMPENSATIONDECLARATION ' APP�ICATION FOR PERMIT �
I hereby afFirm that I have a cenifica�a of conseni to self , .�
insure,or a ceriificate of Workeri Compensolion��sura�ce, 76A364c � - - . . . NEATtNG - VENTIIATING - AIR CONDITIONING a
or a tertified�ropy ihereof(Sec 38D0,1a6.C.) _ _ _ _
Pou� NoKN 561— „ IND.INDEMNITY CE=818(REV.10/81)
r `��+� r
� Certified tapy�s herehy furnished. #�U�O .COUNTY OF LOS ANGELES - BUILDING AND SAFETY
.� Certified mpy is filed with the munry 6uilding inspeo- � � FOR APPLICANT TO FILL 1N - . BWtDiNG n
tion deparlmenl. (PRINT OR TYPE ONLY) � ADDRESS p`Q ,,,� [�
oOe 10-6-87 APP�.�o� SANTIAGO A/C iocnuTru��� ��
NO. TYPE OF APPIIANCE OR EOUIPMENT - FEE �
CERTIFICATE OF EXEMPTION FROM WORKERS - � NEaREST
COMPENSATION INSURANGE � CaOSS Si.
,�Th(s sactioa nead not be compl�ted if fha work Involved by ABSORPTION UNIT,BTU oisiRia No. vaocess BT
ihe parmlf Is lor one hundrad dollar:(SIDO)or lass.) aIR HAND(ING UNIT,CFM � ��
I certify tho�in the performance of Ihe work for which Ihis
permif is issued,1 sholl nm employ ony person in ony manner BORER,BiU
so os to become subjeU to the Workers'Compensation Laws.. nvaaovats onre INSCECTOR'S SIGNATUFE
Dd18 Applicanf� COMPRESSOR,BTU ROUGH
NOTICE TO APPIICANT: If, a(ter moking this CeAificote of veNTaATIONSYSTEM FiNAL � ,,,� �f /j"---
Exemption, you should 6ecome subject to Ihe Workers'
Compensation provisions of the Labor Coda,you must forth- EVn70RnTNE COOIER � VALIDATION
with tomply with such provisions or this permit sholl be
deemed�evoked. FURNACE; FAU GRAVITY
IICENSED CONTRAC70R5�ECLARATION FLOOR BTU � U �D
I hereby affirm that I om licensed under piovisions Of Chapter 9 HFAtER:' SUSPENDED UNIT_ -
'(mmmencing wiih Secfion 7000)of Division 3 of the Business WA«
and Professions Code,ond my license is in full force ond effect. � . - a
L
Ucense Num6er 269496� i;�.aass C-20 `� . . . ' ' � $
� Comrocror SANTIAGO A/C oaie 10-6-87 a
O
❑ u
I am ezempf under Sec. � �
Plan check fee �
B.BP.C.for this reason �
PERMIT ISSUING FEE$ /U �y U r 1 ) �6 A —
oate:
TOTAL FEE p �j, � ��
Signatvre ' �
OWNER-BUILDER DECIARATION � PLAN CHECK APPLICANT '
I hereby affirm Ihal I am exempt from�he Coniro<ror's License , � • i �Q`7�
Law for the following reason(Section 7031.5, Business and NAME
Profenions Code):. • ` � ��%5� .
❑ 1, as awner of the property, or my employees with ADDRESS �
wages as their sole compensation,will do the work and I�1 4_�7
the srrucrore is not intended or oHered for sale�Section Ciiv TEL NO.
70<a,BusinessandProfessionsCode). owNER `i'HE' WILLIAM LY�N CO.
❑ I,as owner of the properly,om exclosively coMrocting � � � ,
with 6tensed mmractors to consrruct the prajecf(SeC- DDRE55 19 CORPOftATE PLAZA
tion 7044.Business and Professions Code).
CONSTRUCTION LENDING AGENCY. qiv � NEWPORT BEACH TEL NO. ' - �
I hereby offirm thaf ihere is o construcrion lending agency Tor ►
fhe performance of the work for which ihis peimit is issued �ONiRACTOR SANTIAGO A/C � -
(Sec.3097.Civ.C.). � � �- - . _ � - ..- . .
nooeess 231 W. BLUBRIDGE AVE.
Lender i Nome
c�rv ORANGE TE`�NO 995-1600
Lender's Address -
STATE LIC.
1 ce�flfy ihot 1 have read fhis appficotion ond stare�hat rhe LICENSE N026�496 CLA55 Ci-2� . � - - � . . �
o6ove in(ormation is correct 1 ogree io camply wilh ail Couny �
ordinances and Sto�e lows relating�o building mnstruction, _.. , , _ .
ond hereby authorize representatfves of this CooMy b enter . .
. upon fhe above-menlioned properry for inspection porposes. - SEE REVERSE FOR EXPLANATORY LANGUAGE _ ... . .
�U����� . � .
$ignaW.e of Applicanl or Ag Da�e �
- � • - � Iwsrecror.�s NoiES OWNEP,-BUIL�ER DECLqRATION .,
� �' • I�horeby af{irm that I am exempi�from t6b�Cantrocror's
`'� ' ' ' '" � � - license Low for the following reason�(Sedlon 70JL5.
.__,_,'.___....... _... _ .._. ..._.._. .... . .. .. .. . ..._,. _ .._.... _ .__._ ..._,._.._._.. ._.. . .' � puslnessondFrolesstonsCode):Anyclryorcounty�whlch
_, � " � . ' � - � - . Yeqvires o perml�lo consfroct.aller,-improve.demolrsh,
---- �- � -- � -� ` � -� � � � � � �- � � � '' '� or cepoir any sirucfure, prlor Io 7h issucnto, olso re� �
� � - �� � , _ .�__'quires�the applicant{or such permit lo iilc o slgnedsrole-
' " - -- �.�._..- _. .� -� � ��-..�.�....'�:' '•1 � .� : � . .. ..��� ment fhaf he is licensedpursucnl fo fhe provlsians o!fhe
� . � � � � , . Controclor's�Lkense Law(Chopfer.9(commenting wllh
�.. " �-�' " . � . . -.�..:.: �` . �.. ..� .. . � ._:... � '- � . Secllon 7000J of Divfs�on 3 0/Ihe.Bus�ness and Proles-
j � _ . - . � . � � � eionz Code)or�ho�he�s erempf�hcrelrom ond fbe'bos�s
� . , � -� . � � �for If�c olleged e emption. Any violaflon of Secfton
_ __ __ �� �_ , 7031:5 by ony applimnf lor o permit sv6jeds 1he appH- �
• , , .. . � � - conf(a a civl!penalty ol nof more fhon five hundred
�. ___ __._ . __ __.. .__. . . . . .. .. . - . _ . dollors(5500).:
.._ .. . % . : . ��..,�..',.... _. . . . ._. � .._ . � - - . � ❑I,os owncr of ihr.praPcrty will do Ihe work,and
� � _ � - , , - �the structure is not inlended or offered for sole. �
-�- -- --� - � - -� - - ---- � (Sec 7044,Buslness and Pro�esslons Code: ,7heConfrao
� � . . , , .ror's lkense Law docs not oppfy fo an owner of properry •
"-- � "" � � � � �wha butlds on,improvos thereon,.nnd who�docs,soch
: . . . . � � work h7mself provided�haf sucb improvemen�s are nol
�� '�� � '_� ' � �� � ''�, � +ntcnded or oHered lor salc.If,howavec�he 6Wlding or
� � �� � . � , 7mprovement Js sold withln ono yeor oF�ompleHon;�ho
' � - � � cwnerbuilder wtl(havc the burden olproving thol he did
. �, - � � �nol build or Improve for 1he purpose ol sale.)-�'�" �
i
- � � ' ❑I,as owner of the propeny,am exclusivcly mn-
. , � . � �� �����tracring wi�h licensed mnirocrors to consrruct the�projecr
, " - - - � �Sec.7044)Ousfness and Prolessions Codc:The Contrar-
� . . � for's Licensc Law does no'opply�o an owner o�property ,
� - who 6oilds or lmproves fherecn,and who controds lor
' ' � � sucb projeth wlth c contracror(s)Ircensed pursudn�io
' : i i � � � �� � -thc Con/rcdor's Grertse Low). � �
.'..�;� f ^ ` . . ' . I am,ezempt under Sec. . ..
� � . �i � ' • � �� - B&�P.C.for fhis reason '
',—1'� i �1 �
,
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� ., .. , . �,... .. . .� . oafe � � . . . .
� ... . ._.'..'-'. . � „�� .. :. ._� ._. . . . Ovmer, ., , ; . ..
INSPEGTOR'S NOTES �� -'.. _. _ . �..-�. '_ .. .. .___ _ � . _. .�