HomeMy WebLinkAbout1164A (5) .WORKERS'COMPENSATION�ECLARATION /y���ICATION FOR PERMIT �
I hereby offrcm Ihat I hove a certificoie of consent lo'self
insure,or o terli/icale of Workers'Compensolion��s��a�ce. � .��3�� � . � HEAT{NG - VENTILATING - AIR CONDITIONING t°N
or o certified copy thereol(Set.3800,lab.C.J � - (
N $G1— CE-819(REV.10/fli) � -'� �- -
��yNoK 4�$�,��Y IND.ENDEMNITY ,
Cerrified copy is here6y tumished. COUNTY OP LOS ANGELES BUfLDW G AND SAFETY
� Certified copy is filed wirh fhe couNy building inspec- FOR APPUCANT TO FILL IN ' � 6uItDiNG
tion deporlment , � (aRiM OR TYVE ONLv) � ADDRESS �
oorel0-6-87 APPi;�a„�SANTIAGO A/('. �ocn�irv�j ;�� �L
ND. TYPE OF APPLIqNCE OR EQUIPMENT fEE u
� CERTIFICATE OF EXEMPTION FROM WORKERS' NEaRE57 ��
COMPENSATION INSURANCE CRO5557.
(Thfs sactfon naed not 6a compl�fod if}hv work Involvvd 6y AB�RPTION UNIT,BTU D�SiRiCI NO. PROCE D BY
the permif ic for ona hundred dollars(SI00)ar bs�.J q�q HANOIING UNIT,CFM '� '�'��,i/`
I tertify that in the performance of the work for which Ihis
permif is iss�ed,I shall not employ any person in any manner BOItfR,BTU
so as lo become sobject ro�he Workers'Compensation Lows. aavaovnis DniE WSPECTOR'S SIGNAiURE
Oa1e � �pplicon� � COMPRESSOR,8TU ROUGH �,1�'" ��
NOTICE TO ACPLICANT: If, oNer mcking fhis Cerlifiwfe Of � VENTILATIONSYSTEM F�NAL '. �S� �-�---
. Exemption, you should become subject to ihe Workers'
Compensa�ion provisions of 7he labo�Code,you musf fo�lh- EVAPORATIVE COOLER VALIDATION v
with comply wi�h such provisions or this permii shall be � � ,
deemed revoked. � FURNACE: fAU GRAVITY ' ' ' � �
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby oi(irm thal I am licen3ed under provisions of Chopter 9 SUSaENDED UNii— � -
HEATER: .WA�� .
� '(commencinq wirh Seaion 7000)of Division 3 of�he Business .
and Professions Code,ond my license idin full force and effect. • � >"'
269496 `� 0.
License Number Lic Class C-2� . � , � {.�!
�
Contractor G�NT T A R/1 4/!• Date 7!1.�_S]4 - . , - d
❑ I am exempl under Sec. , � w�
Plan check fee N
6.8P.C.4or fhis reason pERMIT ISSIJING FEE S /0 ` '—Z
Date:
Sgnarore TOTAL FEE Q ,S� �� � �i 4 1't
OWNER-BUILDER DECIARATION PLAN CHECK AFPUCANT _ �. •.. • •8 ,
I hereby of(irm thor I om exempt from fhe Con7rocror's license
Law for the following reason(Section 703I.5,Business ond NAh1E ' , � I • ��4.7 Jr
Professions Code�: � � �
❑ I, as owner of rhe properfy, or my employees wifh AODRE55 � � � • 1 p 4 7 5�
� ages as their sole compensation,will do tha work and .
. ihe strucWre is not iNended or oifered for sale(Section ��TY 7EL.NO. I Q� U—S 7.
7044,Business and Professions Code�. � � �
owNeR THE WILLIAM LYON C0.
❑ I,as owner ai the property,om exdusively controcting
with licensed contractors�o consrrucr the projecl(Sec- '�`�� �
- tion 7044,Businese and Professions Code): , A�DRE55 19 ORPORATE PI,A'Z.1� � �
. CONSTRt1CTION LENDING AGENCY . CI7Y � TEt.NO. � �
I hereby affirm�hat�here is a conshuction lending ogency for ' � ►
the performance of ihe work for which Ihis pe�mit is issued CONTRACTOR SANTIAGO A C �
(Sec.3097.Civ.C.). .. , -.
� � ADDRESS 1 w. LUERIDGE A E. _ , . � �� . . ...
Lender's Name ',
arr ORANGE rei.No. 998-1600
Lender's Address
I certiFy thof I have read Ihis applicotion ond sfate fhaf Ihe � LICENSE No?69496 � ci ss C-20 . . , . _ . . . . . . . -
- above inlormation is correct.I ag�ee b wmply wirh oll Couny � .
ordinances and Stale laws reloting lo building constroction,. . , _ ,. . ,.
and hereby ao�horize representarives of ih�s Counry ro enter . . � -
upon Ihe above-meNioned property for inspeciion purposes. � SEE REVERSE FOR EAPLANATORY LANGUAGE .. � � , . �. .
/a—G�fr.7
ignature of ApplicaN a.Ager Uab ' � -. . .. � -. � . .
� � � . - � • IKSP6C7oR'S WOTES OWNER-DUILDER D'cCLARA710N ' ;
. ,.. � ��1 horeby offirm thot I om e mpf from the Controctor's
'" ' ` ' �' �icensc law for th^ followinc� reoson (Sctlion 703L5.
...__._......_..__.- ._ ' '.' '_. " ;'�..' .'__.. ... _;.....'__ ...__.. _.. ... . . .,... .�:� .. . - g�slness and Prolessions CodeJ:Any cily o monty which
! . -. .�� - � requires a permit�o mnslrucf.Qller,Imprwe,demolish,
--� "-- " '-—' ' - ' - — ' � �� � � � or repair any sfructure,prlor ro tfs Issuanw, ofso re-
' � � � . � _. ,quires ihu opplitanl for such permH}o lilc o signed sfate�
---� - -� � -�-- -� - � � - � � -� � ' ' ' ment fha�he ts ficensedp�rsuont ro the provfstons o/fhe
� � , � ' - . � Confractor's Liconse Low(Chapter,9(commencing wllh
',""' ""'" ' ' � , "` � ' � � " ' , � � Secfion)000)o!Division 3 of ihc,Business and Prolez-
. , . �sions CodeJ or�ba�he is ezempf there(rom o�d fhc bosis
' ' , i -. for �hc olleged e emption. �ny violation o!Section
�. - --��� �-��--.-.. . ��- --�' -� � - - � � j conf toba clvll pen�alfy'of nopmoro�subjetls 1he oppfl-
, ..� � � - ihan(ive hundred
. � , dollars(S500J.:
'-'----- - --. _ .._ , .._ . . , .
''' ' � - � - � u I,os owner of the property will do the work,ond
� � - � � � � � . . i . � .- the structurc"i:not in'ended ar offered far sale.-�.
�-�--�---- --�-� - - -�- - ' - �� -- - � ' � '� � � (Sec7044,EuslnessandPro�e55ionsCode: 7heControc-
, • , . ror i llcensc law does nof opp(y fo cn ovmer oi properfy
, --- '� , � � who buifds or Improve: lhereon, and who�does suth
. .�.
. _ _ . . � , work himse!!provided Ifiof such improvemen�s are nof
� � � � Inlended ar oflered for sole.If,howevcr,fhe building or
. , . . improvemeM Is sold wlfhin ona year of complefian,thc
- � � � owner6uifder wtlf have fhe 6urden of proving Ihot he did
-. , . . . no�bulld or tmprove for the purpose of sole.) �
� .
� '" � . ❑1,as owner of iho properry,am exclusively com
. � ' . , � � iracting wilh licensed contradors to mnsirud ihe project
�S<c 70d4)Business and Professions Code:The Conkao
� ' � � for's ticense Cow does nof opp(y lo an owncr of property
- - - who butlds or lmproves�hereon,and who tonfroc}s for
. , �� � such projecfs wilh o mntroclor(s)flcensed pursuanf to
� � - - � tRe Confracfor's Cfcense LowJ. �
;1 `'.�1 I � �. . ._. . . . .._ , �
� �- ° ` " ' �� � � � I om exempt under Sec.
„ , ,C� � � ti � . - - . .. - ._ . , .
B&P.C.for this reason
-�.� r���
�a��
� ._. . ._. . . � . �. �O�vner �
�NSPECTOR'S NOTES
. --
i