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Home My WebLink About1449A WORKERS'COMPENSATION DECLARATION aqpp.��ATION FOR PERMIT � � � I here6y affirm ihat I hove a certificate�of consent to self insure,or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified�apy ihereof(Sec.3600,Lab:C.) 76A364C . CE-818(RFV.70/el) . - P�olicy No. Company , Certified,mpy�s here6y furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY�� -r-) � Certified copy is filed with ihe county building inspeo- FOR APPLICANT TO FILL IN eu��o�Nc. ) tiondepariment. � � � ADDRESS [�,� "-3 ��^(j'��1� - (PRINT OR TYPE ONLY) Date Applicant- � � � LOULITY ��;� . NO. TVPE OF APPLIANCE OR EOUIPMENT �- � � FEE � , CER7IFICATE OF EXEMPTION FROM WORKERS' . NEAREST �J COMPENSATION INSURANCE � � CROSS ST. [(J ^�f1, <}nt��iJ L3I(1'CI (This seation need not be complefed if the work involved 6y ABSORPnON UNIT,Biu oisreicr Na. vzocesseo ev fhe permit is for one hundred dollars(5100)or less.) . � � I ceriify that in ihe performance of fhe work for which this A�R HANouNG uNir,CFnn permit is issued,I shall nof employ any person in pny�manner BOILER,8TU so as ta become subjec�to�ihe Workers'Compensation Lows. n�veovai;. onte iNsaecroa's sicNqtuae �J..� . � COMPRESSDR, U �aj�L��7 �'1-�-Ln (�U 4 ROUGH `� Date /+pplimnt � �� NO710E�TO APPLICANT: If, afrer making ihis Cerfificate of � VENTIL4TION T � ^r .. L /J d FINAL � .�`a.- Exemption, you should became subject to the Warkers' . Compenspiion provisions of the Labor Code,you must forlh- ' EVAPORAiNE R VALIDATIONI- .with comply with such provisions or ihis permit sholl be deemed�evoked. - FURNACE: FAU GRAVITY ^ Q� � � � UCENSED CONTRACTORS DECLARATION FLOOR � BTU U - . I he�eby affirm thai I am licensed under provisions of Chapfer 9 HEATER: SUSPENDED UNIT_ �[commencing with Section 7000)of Division 3 of�he Business �� WA�� and Professions Code,and my.license�is in full force and effect . � . �i License Number ��,��a 7 Lic.Class �'�� . � � � Contracfor� Dafe �1"�5'�� ❑ I am exempt under Sec W Plcn check fee � B.&P.C.for ihis reason� � � PERMIT ISSUING FEE j Q,r� � Dat s.a �� e �� TOTAL FEE ,S<J . OWNER-BUIIDER DECLARATION P�nN cHECK naauCANT . I hereby affirm ihat I am exempt from the Controctor's License . ► � Law for the following reasan (Section 7031.5, Business and NAME ' Professions Code): � � � � � ' '� ` - ❑ I, as owner of ihe property, or my employees with ADDRESS y � !� ages as iheir sole compensat on,will do ihe work and - ihe strutlure is not intended or offered for sale(Section CITv - . TEL.NO. � ��. 7044,Business and Professlons Code). � - OWNER �-�� - _ ❑ I,os owner of the property,am exclusively coniracfing r - - �-� with licensed coniradors to construct the project(Ser MA1L . � ?ion 7044,Business and Professions Code). . ADDRE55 , ,'�z CONSTRUCTION LENDING AGENCY a7Y �� Te�.n10. � I herehy affirm that ihere is a consfruction lending agency for � � the performance of ihe work for which this permit is issued �coNikAcioA � � � , � � (Sec.3097,Civ.C.). Jd _ , . ADDRESS L t lr�/�'LU.Y�U� . . � . Lender's Name Lender'sAddress C�TY 'i� � TEL NO. ��-��y�''�j . . � t � I ceriif that I have read ihis a limtion and state ihat ihe 57A7E q� (� uC /^ � y pp LICENSE NO. ,.e� p� CW55 �l'��C�' . above information is rorrect.I agree ro mmply wiih all Coun�y . � � . � ordinances and State laws relatina to building constructioq � � and hereby autharize representatives of this Counry fa enter , � � � � u�pon the apybove- �tion�ed prope�fy for inspedion purposes. SEE IfEVERSE FOR EXPLANAiORY LANGUAGE C1�^�L-h �0"Gvi�kw C�'-��i'"z1� � . . . . . Signof�re oF Appiicant o�Agent �are _ . � � INS EtT9R'S tdOTE3 QWNER-��JICDER C3ECLR�ATION . , I heraby aftirm ihaP I arts exempt from the Cuntrdcfor's ,, , � �� , � License Law for ihe follo+,ving.reason !Section 703�.5, ' - � , . � � � - ' - "eus7ness aod Professtons Codel:Any ciPy or coun!y wfiich � , � " . '- - �� requlres a permi!to con5rruct olter,improve,demolish, . �- � � . - � � or repair cny sfructure, prior po its issuonce, also re- � � , . .. � gyires fhe appficont for suth permif 4o flle a sfgned state- . - ' -- . � ment fhat he is Iicensedpursuonf to ihe pravislans of the � . � - � � � ' ' � . � Confr6c6or's Lieense Caw(Chopser 4 ftommencing wifh � . � � � � - Seatlon 7pQ0)of�ivis!cn 3 of the Eusiress and Proies- � - � . � sions Coda)or that h�is exempt fherefrom and the 6osis � . - - � �� for the dlleged axampfrcn. ,4ny vialm•ion of 5ection . � . � _ . � � 7031.5 by ony app(icant for�a Permit sub�ects ihe appli� � � - . . � � cant ta a civil penalTy of nat more lhan flve hundred� � -� � . � - � dollars($500j.: , � � - �� - ❑I,es owner of the propersy w��ll do ihe work,and , � . .. . � . � . . � the s`rocture is noi intended or offered for sale. � � � � � � - �� j5ec 7044,Business ond Profess.ions Code: The Confroc-� - - . . �' ^ tor's License Law does nor apply to an owner of proper7y � � , who bvtlds or improva, Phereon, and who daes such . � . � ' . work himseli provided tnat such improvemenis are nct� � - � � �� intendedon offered for snle.If,however,rhe 6ui(ding or . . . � irnproverren�is soid wdphln cne year ov compiet/on,the . � � ownervbudderwfll F,ave�he 6urden of proving thaP he did . � - not bWld or improve f¢r the purpose of safe.) � � - ❑1,as ov✓ner ot iF,e propeci��,om exdusivelv ccn- � Prccting witF,licensed mn;rocteis to mnstrucr+ha projec. � � � � (Sec.70A4)Bus'rness and Professions Code�:7he Cont�oo- , ' � for's ticerse Law does not apply to on owner of property � _ who buifds or imprcves Ph�reon,and wfro contracTs£or � . � . - such Froje�ts wif6 a contea[tor(s)lfcensed pursuvnl io . � ihe Coniractor's Lecense iaw[ � � � - I am exempt under Sec._ B&F.C.for this reason Date � - � . � Owner - � INSPSCTOR'S NOTES