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Home My WebLink About1501AWORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, Pf qro a certi�e� copyThereof (Sec. 3800, Lab. ) ' L ❑lihCly4(V! ' co y C hereby Ce tified ropy is hereby furnished. Certified copy is filed with the county building inspec- tion deportment. Date-/Lr'i Applicant CERTIFICATE OF EXEMPTION FROM WO CERS' COMPENSATION INSURANCE (This section need not be completed if the work Involved by the permit Is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. Date- Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 '(commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Number ;96095196 Lic. Class 't� z U Contractor-.�% - 1 Date 1(Y1(o-9 ❑[am exempt under Sec. B.BP.C. for this reason OWNER -BUILDER DECLARATION I hereby offirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Code): ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm Ihot there is a construction lending agency for -Ihe performance of the work for which this permit is issued (Sec. 3097, Ci, C.). Lender's Name Lender's Address I certify that I hove read this application and state that the above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter on the above-mentioned property for inspection purposes. - - /G -/t. --S, 7 Signature of Appliconr or Agenyq Dore APPLICATION FOR PERMIT y3 76A764C HEATING - VENTILATING - AIR CONDITIONING L� CE -SIB (REV. 10i8t) COUNTY OF LOS ANGELES BUILDING AND SAFETY c7 fJ0( f FOR APPLICANT TO FILL IN (PRINT OR TYPE ONLY) BUILDING ADDRESS 201/,r NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY •LC.�r.+tJ+-+�' NEAREST CROSS `'/` ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY AIR HANDLING UNIT, CFM BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE COMPRESSOR, BTU ROUGH �QEB VENTILATION SYSTEM FINAL EVAPORATIVE COOLER ` ► - VALIDATION - 5 Q 1 A • • ' ' 8 I • -74,75 • • • 7 (j, 7 rj U I O.2 1 8 7 - - FURNACE: FAU 21 GAVITY /D FLOOR BTU ✓'� HEATER: SUSPENDED-UNIT- USPENDEDUNIT_WALL WALL 6V as Plan check fee PERMIT ISSUING FEE $;E1 TOTAL FEErf % PLAN CHECK APPLICANT NAME ADDRESS CITY NO. pTEL. OWNER MAIL ADDRESS CIT TEL. NO. ' CONTRAC RS - /7/ l./ ADDRESS 3/ CITY TEL. NO. STATE ��E1 [yc� Lic LICENSE NO.a / ♦ CLASS 4,o" 7— SEE REVERSE FOR EXPLANATORY LANGUAGE "INSPECTOR'S NOTES OWNER -BUILDER DECLARATION 'I ho'c6y'offiim that I am exempt from file Contractor's License Law for the following reason (Section 7031.5, Business and Frofesslons Code): Any city orcounty which '� �',, - �'•, �- , s�. - req ulres o permit to ceps truct, altar- Inn pro va, domolis h, -- _ - - - - - or ropair,ony structureprior to Its Issuance, also re- ! i\ ` �-� - •. quires the appl_imnl/orsuchparmltlo}ileaslgnedstafc- __._ _ �� \ - ment that he Is licensed pursuant to the provisions of the Contracfor's License Low (Chapter 9 (commencing with - - - - - Section 7000) of Division 3 of the Business and Profes. sions Code) or that he Is exempt therefrom and the basis - for the alfegad exemption. Any violation of Section 7031.5 by any applicant lora permit subjects the appli- - - - - - - cant to a civil penalty. of not more than five hundred - - - - --" - - - - - - -- - -- dollars (5500).: ❑ I, as owner of the properly will do the work, and the structure is not intended or offered for safe.. -- -' -- - - - - - (Sec. 7044, Business and Professions Code; The Coniroc- for's License Low docs not apply to an owner of property _ who builds ar improves thereon,, and who does such work himself provided that such Improvements are not _ intended or offered for safe. If, however, the building or - improvement is said wilhin one year of completion,. the - - - owner -builder will hove the burden of proving that he did - - -, not build or improve for the purpose'of sale.) _ .. - - _,❑ I, as owner of the property, am exclusively con- 1—ting with licensed contractors to construct the project (Sec 7044) 6ustness and Professions Code: The Centrec- for s License Law does not apply to vWowner of property who builds or Improves thereon, and who contracts for t _ - such projects with a controcfor(s) licensed pursuonf to _ _ _ _ . - the Contractor's License Law). '