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HomeMy WebLinkAbout1167A (5) ' WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PERMIT � I he�eby a(fkm tho� I have a certifimte of consenl io self � �nsure,o�a cerrifimte of worke�i Compensmio�i„s�,o��e, ��364C HEATING - VENiIIATING - AIR CONDITIONING or a certified mpy Ihereo((Sec.3800,Lob.C.) a 9 Poi;�YNoKN 861-9��,��Y IND.ENDFMnrrTv `�-B,e�RE,,.,o�e�� ❑ Certified copy is here6y furnished. #-3 frD COUNTY OF LOS ANGELES BUIIDING ANO SAFETY � Certified copy iz filed wirh the counry building insper FOR APPLICANT TO FILL IN euitoiN� fion department.-� (PRIM OR TVPE ONLY) ADDRESS C � �,yf �D oate 10-6-87 APPlimn� SANTIAGO A/C �ocnuTv�' • . NO. TVPE OF APPLIANCE OR EOUIPMENT FEE' '� �J CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST ' COMPENSATION INSURANCE � CRO55 57 ' ✓ j (Thie�ectlon naed not bo complated I(fhe work inrolved by ABSORPTiON UNii,B7U oaraici No. vaoccs o er Ih�permtT L!or one bvndrod dollars(5100)or lass.) � qIR HANDLING UNIT,CFM pZ �rn I certify that in the performance of the work for which rhis �� permi�is issued,I shall not employ any person in ony manner sa os 7o become�subject to fhe Workeri Compenspfion�pw5. . 601LER,BTU AGPFOVAlS p4iE INSFECTOR'S SIGNATURE Oate epp�imnt COMPRESSOR,BTU ROUGN �30',}� � NOTICE TO APPIICANT: li, oher making this Certificale of VENTIIATION SVSTEM � FiNAL ��.q�. !i- Exemprion, you should 6ecome subjed to the Workers'. Compensation provisions of�he labor Code,you musl(orth- EVAPORATIVE COOIER VALIDATION with comply wilh such provisians or this permi�shall be Cleemed re�okeCJ. - FURNACE: FAU VRV . . IICENSED CON7RACTORS OECLARAiION FLOOe BTU O7� ' I hereby affirm tho�I am licensed vnder provisions of Chapter 9 SUSPENDED UNIT_ ' . . `(commencing wilh Section 7000)of Division 3 of the Business HEATER: WALL ' ' and Professions Code,and my license is in full force ond effecL _ _ . � ' - �" 3/ �5� �� n. License Number 269496 Lic Class C-2(1 � , � SANTIAGO A/C Daie 10-6-87 0 Conrroctor � - - " � ❑ I am exempt onder Sec. ._ � . � uV+ Plan check fee -1 1 6 7 F� y e.&P.C.for this reason PERMIT ISSUING fEE S / S— �i• • • • •S � '. Date: stqnaru.e TOTAL FEE p OWNER-BUILDER DECLARATION PLAN CHECK AFPLICANT � � . � Q Q,�I�j I hereby aff�rm thaf I am'exempt trom rhe Controctor's License Low for the tollowing reason(Sedion 7031.5, Business and NnME ' • ° � ��7 5� Professions Code):� - ❑ I, as owner of ihe property, or my employees with AD�RE55 � I Q� �l—S I �� wages as lheir sole tompensolion,will do ihe work and �iTY TEL.NO. � the struclure is not intended or offered for sale(Seclion 7044,Business ond Professions Code). THE WILLIAM LYON C0. � OWNER ❑ I,as owner of the properfy,om exdusively coniroUing wilh li[ensed coNrectors to conslruct Ihe projed(Sec- � �'�� � - � . � . tion 7044,Business and Professions Code). aooseSS P $j� CONSTRUCTION LENDING AGENCY � CI7Y NEWPORT BEACH re�.r,o.� - � �� � � � I here6y affiim that lhere is a consiruclion lending agency for , Ihe performance of the work for whith Ihis permi�is issued- CONTRnR02 SANTIAGO A/C �� � (Sec 3097.Civ.C.). . .. - . . Lender's Nome � ADDRE55 �RIDGE�AVE. � � � - � � � � - - c�Tr ORANGE TE� "0 9gg_1600 . Lender's Address . - I cenify fhof I have read Ihis appliwtion and stale that the� � LICENSE NO.`Zf19496 ' C1A55 �C—�+�� � �-. --.. . . -..... . . . . . . above informo�ion is mrrect.I agree to mmply with oll County � ° ardinances and S�a�e laws relaling lo building construction, , __ _ _ _ _ ._ and hereby aothorize representolives of this Coun�y 10 enter � � � - - upon Ihe above-mentioned property for inspection purposev SEE REYERSE FOR EXPLANA70RY IANGUAGE �►zti-r-.... � /D—G—fr 7 � _ S�gnoiure ol Applkon�o.Agen ' Doie . . �- ' " " � InSr€cTOR'S NOTES OWNER-E3UILDER DECLARATION ,. . � --- �I hcroby affirm thal�am exempt'from the Conlroctor's "� ' ` � � ' �� license Law for rhe.following rebson�(Secflon 7031.5, .._. . _�.... .._.... ._ . . __._ . .. _. .. ..-.i_ . .._ '__ -�.. ., . ._'_.._ _.. . ....__.. . '�. . , ..-.. . ...._. . . . . - - Buslness and P�o/essions Code):Any city or county wMch _ � � �� - � � - - - requires a permN fo construcf,eller,improve,demolish, . �'-"-" - '� � " ��� � -� '- -�� ' ' � or repair ony S�NCiJfq rflOf�IO ils Issuonrc, also rc� ' � � � �� - � . qvlres Ihe opplicanl!or such permff ro life a slgned sta}e- � . � -�- �� �� ��- - . - � �� �- � � � ' - � ' menf Ihat,he Is litensed parsuent}o the provislons ol the , � � � . � .. . Conlrodor's Llcense Low,(Chopter'9(rommencing wilh _._' . :.. . .. .: .. .:.�. .' '-�'_�. _ . i . , � , , � Se[lion 7000)ol Dlvis�on J of fhe Buslness and Profos� ' ' � , � • � sions CodeJ o:ihat he Is exempt�hcrelrom and fhe basis � � � � ' ; �(or the alleged exemption. l.ny violofion oi Secfion � �' . . ' '. �� '� �..� .. � � P Y for a permit su6jecfs�the appli- . .. . . . ... .__..� ... ._ ...__ � � . -� . � . � �• � � �� - ....._.. . �.� �. . canf toba Nv'f Peoall'�of nof morc thon fivc hundred ..____ ._._.__ .. _ . . . -__ . . dollors(5500).: � _ _ � � _ - ' � - � � � ❑I,os owncr of�6e properry will do Ihe work„ond ' , , _ . thc slruclure-is not in!ended-cr offered for soic: � � � � � ''� -� � . -� ' . �� ' ' � � (Sec.7044,IIvsiness ondPralessions Code:��� iBeConlroo- � � . ' ' � , . . . � . �or's Llcensc Low daes not opply,to an owner of property � -�-- -� � . � � who�bullds or�improves thcreon, and who does soch , .. . � work hlmself proWded that such improvemenfs ore not . _ . ' � - � � infended or olleted for sofc:If,however,�he building or � . __ ._ . � �improvemenl Is sold wi�hin one year ol mmplvffon,.the , �._ _ ..�,._ �� ��-_ �� - � > _ - �ownar6uifder will have Ihe burden olprov7ng l6af he did _ �_� � . . 'nof bulfd or Improve for ihe pwpose of salc.) ' � ' ❑I,q,owner oF Iho property,am exclusively con- � � � - � - ��tracting with licensed contractors to c�ons�ruct the�p^oje<t � � . - - - � (Sec.7044)Businezz�and Profmsions Cade:ihc Confroc � -� -'� �or's i�cense Low docs no�apply�to an"owner oiproperly . - � � i � --�� -� - � � - who�boild,or improves iheteon,cnd who confrads lor � � � �� '�� �� � such pro(eds viifh a confractor(s)licensed pursuont fo .. . .._ ._ _ . __ . . __ .. �� ,� , , , � „ . - - fhe Confrecbr's L(cense Low). � "� ._ . , . _ __.._ _ ...__. _ . . " ,_ . ^ .,'� I ^ � . � . .. ... �� � I am ezempt under Sec. � - i � " . . � � � � . �. _ \ B&f.C.for this reason � � i ''? 1 __--... - - _ �ate � _ . . _.. . . , . ,� . .. ' . .' . � . . . Owner � . . . . _ � . t , . , . . � . � . . . , INSPECTOR'S NOiES � �-� -- -- -- � - �- � - - � . � � �. . � .. . �