HomeMy WebLinkAbout1507AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self APPLICATION FOR PERMIT
insure, or a certificate of Workers' Compensation Insurance.' CE•
I.
(REV. 10/81) COUNTY OF LOS ANGELES - BUILDING
��Qp(('//�,[�[a!� �//tiffyd cpJ}y .of (Sec. 3e Lo/b�. 76A364c _ :HEATING 'VENTILATING - AIR CONDITIONING
P❑o• fitfit fTo.l Com an ` _, t .
Certified copy is hereby furnished. - - DING AND SAFETY
Certified copy is filed with the county building inspec- -
"an department.
Date /d ��� Applicant
CERTIFICATE OF EXEMPTION FROM W06415' - - ---
COMPENSATION INSURANCE
- (Thts seetlon need not be completed if the work Involved by
the permit is for one hundred dollars ($100) or lass.)
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
NOTICETOAPPLICANT: 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 C265"'12 6 11cCIas4 e` -Z�U -
ContracfoJ Date 61L— &-'� 7
❑ I am exempt un er Sec.
B.BP,C. for this reason
Signature - -
OWNER -BUILDER DECLARATION - -
1 hereby affirm 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 employeeswith
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 that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
certify that I have read this application and state that the .,
Y 3 i/ d
r3Vo v
FOR APPLICANT TO FILL IN - -
(PRINT OR TYPE ONLY)
BUILDING
ADDRESS
773 GC.rs-7 (�L�i7•dC.•ss.[i A—�
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
LOCALITY
n
PJ
NEARST. EST
CROSS
L%
ABSORPTION UNIT, BTU
DISTRICT NO.
-
�%
PROCESSED BY
T
AIR HANDLING UNIT, CFM
BOILER, BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
COMPRESSOR, BTU
ROUGH
U& -S& I
VENTILATION SYSTEM
FINAL
Z8
EVAPORATIVE COOLER
►
_. _.._. ._
VALIDATION _
1 5 G 7 A
• • • • 8
I • -74.75
• e • 7475v
IG21-87
-
-
-
- -
_.-. .. ...... _. ... .. .. ... .. ._ ..
/ FURNACE: FAU TY _ -
/ FLOOR BTU 0
HEATER: SUSPENDED UNIT=
WALL
3.
Plan check fee '
-PERMIT ISSUING FEE S /Q 5—
TOTAL FEE `J y
PLAN CHECK APPLICANT
NAME
ADDRESS -
CITY TEL NO.
OWNER
�t/��iYvt Q7✓
MAIL ..
ADDRESS
CITY -- TEI. NO.
CONTRACT - - .."...
ADDRESS
CIp .. TEL..NO...
[�/
STATE
LICENSE NO. G / l CLASS Com_-Zo._.
above information is correct. 1 agree to comply with all County -
ordinances and State laws relating to building construction,
-
ond hereby authorize representatives of this County to enter-
pon theabove-mentioned property for inspection purposes. - SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent a Dote'- - "--
Q
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Ce
O
V
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INSPECTOR'S NOTES
OWNER-BUILD ER DECLARATION
`t f{
Com
l.�'�• j L, :`�- „- .
�' I hereby toff rm •thara am exe p+. f m the actor's
} r _ , r
-'= "•"-"•'--"-1
License Law for'the following reason f5ection 7031.5.
Business and Professions Code J Any city ofcounty wh1Ch
requires a permit to construct, alley I.. prove, _demolish,
I
or repair any s 'Issuance, also r.
applicant for
`, quires the uchlpermifoffoille'o slgnoedstw..
t -�. _ •,
•• \� \ '.i h
me f that he is licenseduanl } f provisions of the
purs heprov
Conir',cfors. License-Low Chapter(commencing with
1 \1.. �`� 1 ,'.
; ' I � _ __-_ .. �"� � �� -
�
,9
Section 7000) of b vision 3 of the Business and P,rofez.
cmpk
ions Code) or shot he Ise fherefromand fho basis
for the alleged eirempf on _, Any violation of Sacffon
7031.5 b an op Iican} fa{:a pe'subjects the apple-
prmit
i
cant to acivil penu'lt y „of not more than five hundred
,
dollars
1 .• _ -._.. . _.._.. . _. "' - • �
❑ I, as owner of Jho property will do the work,.ond :
the structure is-nal intended or offered for sale
.---—.----.-- ------ "-..-- ---- •—i-__ i
�:..-,, fSec.7044, Business ondProfessfons Codo:' Tho Confroc- -
_
s • 1r ., ;
- •- • tor's License Law does not apply;fo an owner of property
.
who builds. or improves thereon,andwho does such
\
work himself provided that such improvements ore not
_
< ; S _ _ _ \ '
intended or offered forsole: lb however, the building or
i -__ -. - -, .. ,,
, • .., Improvement Is sold within one year of completion, the
- - - - --
-fi
. ownei�•bullder will have the burden of proving that he did "
'nof bulfd or improve for the purposeof safe.)
I, as ownei`of .the pr.opertY, am exclusively con-
.
trading with Ilcensed caniractors'fo;constfuci the project
- _ .. .I 1 .. ._...._.___:._._ ._.._.__.... .._ _.._-__-. ._.;
.(Sec.7044)Business and Prof... tons Codo: TP. Controo -
- - — for's'Licen,e Low does not appfy'to wn 6wncr of property
_who builds or Improves thereon, and who copfrocts for
such projects with a confractor(s) licensed pursuant to
- r -- - - -- - --- - -- -- - -
it
— '-the Contracfar's License Ldv,J.'
,
-
1 am exempt under Sec.
o
B 8 P. C. for This reason_ • -
-r>U, 1
Dote
Owner
INSPECTOR'S NOTES , I
r._
t �.