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Home My WebLink About1648A WORKERS'COMPENSATION�ECLARATION APPLICATION FOR PERMIT �� I hereby affirm ihat I have a certificate of consent to self � � insura,or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING • AIR CONDITIONING or a certified copy fhereof�(Sec.3800,Lab.C.) ?�3� - . CE-818(REV.10/Bl'�� Pofcy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY � � � Cerfified copy is hereby furnished. � � � � � � .Certified<opy is filed with tMe couny�buildiny i�spec- FOR APPLICANT TO fILL IN � eu��Nc� tion depariment. . � (PRINT OR TYPE ONLY) ADDRE55 %,�. — a� �y'G��''!' Dafe Applicant _ � �. . . LOCALITY ��r}�" NO. TVFE OF APPLIANCE OR EQUIPMENT � . FEE /� CERTIFl COMPENSATION�INSURANCEORKERS' , . , C OSS ST. ��C/' " �(y}�C. � ��,,l� (This seefion need nof be eomple�ed ii ehe work involved by ABSokaiioN uNli,-BiU cisraia No. - Peocesseo ev - the permiT is for one hundred dollars(f100)or less.) qIR HANDLING UNIT,CFM - - I certify that in ihe performance of ihe work for which this . . � permit is issoed,I shpll noYemploy pny peFson in any manner so as fo bemme subjed to the Workers'Compensafion Laws. BOILER,B7U qaveovais oAie iNsveciok'SS��Nnluae � Date Applimni COMPRESSOR,�BTU ��Of�L� .�i+z+�0a'�r ��`� ROUGH �� . NOTICE TO APPLICANT: If, after making ihis Certificate of A� VENTILATION �� FINAL r�� Exemption, you should become subjecf to the Workers' 1Cr5 Compensotion provisions�04 the Labor Code,you must forfh- EVAPORATIVE COOLER VALIDA710N - with comply.wifh such provisions or this permit-sholl be � deemed revoked. FURNACE: FAU GRAVITY - ��d� LICENSED CONTRACTORS DECLARATION FLOOR eTU I hereby affirm that I am licensed under provisions of Chopier 9 � SuSaeNoeo UNIT_ � � , , � �(mmmencing with Section 7000J of�ivision 3 of fhe Business HEATER: WA�� ond Professions Code,and my license is in full force and effect. � � . . � License Number 'Y�0��.�.� Lic.Class �''�� - ► � V Q � Coniractor��5�� 1�� pate ��a"[J� � �� ❑ I om exempf under Sec. �- � '-��'-�-�� ,p Plcn check fee a v� e.&P.C.for�his reason PERMIT I$SUING FEE$ (� :� � � � � Da e: � g TOTAL FEE �j D 5'anature�.Y":.0�'�lh e�L�.u� ' ' - �'"' OWNER-BUILDER DECLARATION � PLAN CHECK APPLICANT , ., , , I here6y affirm ihat I am exempt from ihe Contractor's License , , � Law for the following reason (Section 703L5, Business and NAME � � . � ,, , - Professions Code): � �. . - ❑ I, as owner of the properfy, or my employees with ADDRESS � � . � ages as iheir sole compensoiion,will do the work and � � �� - ihe shucture is not intended or offered for sale(Section CITV � � 7EL NO. 7044,Business and Professions Code?. � � -]� � - � OWNER `FQ _ �NS I ❑ I,as owner of the property,am exdusively confraciing � wiih licensed contra<tors to construct the projeU(Seo MAIL - � iion 7044,Business and Professians Code). ADDRE55 CONSTRUCTION LENDWG AGENCY air te�.No. � I here6y affirm ihat ihere is a construcfion lending ogen<y for , , � the performance of the work for which this permit is issued CONTRACTOR�� .�,.� � � � (Sec.3097,Civ.C.). . � p � . � ADDRE55 !��'J+7 „/��A . �� Lender's Name ° � � � Lender's Addreu ��ry �j� _y�Sl[l�' TEL NO. .��('�C fZ� . STATE . LIC. - I certify thot I hove read this appiication and state ihat ihe LICENSE NO.� � .�. � CLA55 � � . - above information is correc±.I agree to comply with all County � � � ordinan<es and State lows relating to building construction,� - . � . - and hereby authorize representatives of ihis Counry to eNer . . upon the above-mentioned property for inspection purpases � SEE REVERSE FOR EXPLANATORY LANGUAGE � �.�P�� -��.�-� Signature of Aoplicant or Agent Date - � � ' � ' 1NSP�CTQR'S N�TFS OWI4ER-�iJILDER DECLARATIUN � . - � � . . � � - I hare6y affirm+hat I�m exempi from 9he CCntroctor's � � � � � �- � � License Law for the following reoson fSection 703I.5. - � � � �� -� ' Business and Proiessians Codel:Any ciry or couniy whieh ' - � � _ , - - �� requires a permit fo cons}ruct,aHer,improve,damo(ish, � - � �-� � � " � _ �or repair ony structure, prtor to!ts issuonca, also re- , . . . . . . . . . . _ . . . . _...4vires 6he gpplimnt faf such permit!o file a signed sfafe- . � � � - ment that he is licensmd pursuont to the provisions of the . � - ' � � . ' � Controdar's License Low(Chapter 9(commenc'rn�wiih � � . � � � � � � Secfion 70U0)of Divistom3 of ihe Susiness.and Profes- - T^ � . , sians Gode)or ihot he ts exempt.sherefrom and fhe basis � . � � Oor ihe olleged�exerrptron. Any vio7afion of Section . . . . . P031.5 6y any applicont for o permit subjects the oppfi- . � - - . � � �� cant to a civ7!penalty of not more fhan f'rve hundred . , . . � � dollars(%5{�0).: . -� � � � � � ❑I,cs owner ot?he properry wili dc'ne work,and . � � � ' � th�structure is not Intended or cffer�d for sale. � � � � � �� (Sec.7G44,Business artd Professions Code: The Contrac- �� . tor's License Low does rtai apply to an owner of property � � wno builds or rmproves ihereon, and wfio does such . � ��- . . . work himse(f provided tnai�suc�h improvemen}g are not � � � intended or oiferec�f8r sale.If,however,the building or � . , . . . � .improvem�nt.is sold w7tnin cne year of completion,ihe � . � owner-builder will Fave fbe bvrden of�proving thaT he did ' no1 build or improve for 7he pur;cose o/sa/�.) _ � ___ _ - ' ❑1,as owner of i5e property,om exdusively con- � � trociing with licensed.coniractors to ron=truct the projed . � (Sec 704bj�us"rness and Professions:Code;The CoMrac- � - - . � �tor's Cicense Law daes not opply to an owner of properiy � � who builds or lmproves fhereon,ond wf7c controcis for � ' � - � � sucl�projecis svith c contractor(s)licensed pursusrni 10 _ the Cont:acior's License La�roj. - . � � � I om exempt under Sec. � . . � B&P.C.far tnis reaso� - � � � � � Date � . , � . . - . . � � 4wner � iNSPECTOR'S NOTES