HomeMy WebLinkAbout0787A 2094A WORKERSCOMPENSATIONDECLARATION � AppLSCATION FOR PERMIT �
I hereby aFSirm that I have a certifimte of mnsent to self
insure,oi.h certifimte of Workers'Compensation Insuronce, �6A364C HEATING - VENTILATING - AIR CONDITIONING
or a certified copy Ihereof(Sec 3800,Lab.C.1
CE-818(REV.10/Sl�
P❑olicy t�o. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Ce�tif�ed copy is hereby f�rnished.
� Certified copy is filed with the munry building inspeo- FOR APPLICANT TO FILL IN BURoiNG Gq ,// _ � /
ADDRE55
tion deparfinent. iPRINT OR 7VPE ONLV7 r� /l/� Qr✓ov
Date Applimnt iOCALIiv ��
NO. TVPE OF APPLIANCE OR EDUIPMEM FEE
CERTIFICATE OF EXEMP710N FkOM�WORKERS' NEAREST
COMPENSATION INSURANCE �RO55 Sr.
(Tbis seefion need nof be eomplefed if ihe work involved by ABSORPTION UNIT.B7U oi5rkic�Ne. PRocessee av
ehe permi�is for one hundred dollare(5100)or less.) �Q
I cer�ify thal in ihe performance of Ihe work for which ihis AIR HANDLING UNIT,CFM
permit is issued,I sha�l not employ any person in any monner g���ER,B7U
so as to bemme subject to the Workers'Compensa�ion s. ;.weovnis onTe iNSPecroa�ss���+;nruae
/Q
COMPRESSOR,B7U ROUGH L�f
Date�_�—.Applicant � - `='`��
NOTICE TO APPLICANT: If, af r <ing this Cer7ifiwte of VENTILATION SVS7EM `�NAI �^=7.. ,ty,�(�,;
Exemp�ion, you should become sobject ro the Workers'
Compensation pravisions of the Lobor Code,you must fortn- EVAPORATIV:COOLER VALIDATION
with comply wi�h such provisions or this permit sholl be
deemed revoked. FURNACE: FAU_GRAVITY
LICENSED CONTRACTORS DECIARATION ROOR BiU
I hereby affirm fhat I am licensed under provisions of Chapier 9 HEAIER� SUSPENDED UNI7_
�(commencing with Section�00p)of Division 3 of the Business � � 'N/+��
and Professions Code,and my license is in full force ond effed. � /,� , }
�/ ,aCs�v,.�� rz�L �S h1 �
License Nu�� /� � Lic.Class� , ',G,���A V
�
Coniractor� � ��.� Cl�Dote� h!�,E.K o�2 �
❑ I am exempt under Sec , �
Plan check fee ���j� I .�� � %�p �
B.&P.C.for this reason
PERMIT ISSUING FEE� v S��} n., �+ ; �,ti�� �
Date:
Signoi�re TOTAL FEE �,� � C_�b
OWNER-BUILDER DECLARATION P�AN CHECK AFPLICANT �
I hereby affirm�hat I om exempt from rhe Coniroctor's License � , .
Low for the following reason (Secfion 703L5, Business and NAME �R�'�'�
Professions Codel: �
n�oRess � � C l � _�:G y 4 R,
❑ I, as ewner of !he properly, or my employees with r�
waqes as their sole mmpensation,will do the(rk and CI7V ��a/J'�`� TEL NO��/"gs��� „ ,n c .,
the structure Is not intended or offered for sale Sedion � 4
i—rv �
7044,Business and Professlons Codel. I � �-J.;7 e
OVJNER S C� �/f L�/�-
❑ I,as owner of the property,am exclusivel contwcrin �
� with licensed coniradors?o construct the projed(Sec9- .MAIL � - `'J�.�{j�
tian 7044,Business ond ProFessions Code). ADDRESS
CONSTRUCTION LENDING AGENCY Crtv iEL NO. �%� ? ����'
I here6y affirm fhat there is a construc�ion lending agency for
fhe performonce of�he work for which fhis permit is issued CONTRAC70R Cs � �
(Sec.3097,Gv.C.).
ADDRESS ��^ Gl �,C�
Lender's Name ��
Lender's Address cliY ��1 iEL NO� S ��``�Z
""�VV
STATE [/t'^�J LIC. ,%
I certi{y thar I hove read this app��cation ond stote ihat 1he iiCENSE NQ � (•� ( CLA55 �C5 �
above informotion is mrrect.I agree ro wmply with all County �
ordinances cnd Slate laws relating!o building consrruction, � `,
and here utho•ize repres ta��ves of this Couny to ente� .-.s� - c .,,
upon f o �lfoned pr pe�ty for inspe<tion purposes. � - f',; � � j''/ •
.,: r„�. . �'.
� ��,��� SEE REVERSE FOR EXPLANATORN LANGUAGE r �"'^^^' c . ; � � .. ._... ..____ . .,
� - �
igna App i ni ar Ageni Daro �
a w�,_
ii�s�Ee��a's N@Y�S ----- fi��EaER-cUl�CE2 D�c�A�ar;��v,:
. I herebv nifirui'ha':om cxen�.n!>ram the Ccr.iractor's
- - - � '—� Llcer:se I.�w for t6e fo;lawlno rauson .' c!iq,� 7�3i.5,
. S�SIt't�55 f]�:Q'i�fOie?SSi..�i�5 CGdC-f'�'anyCii}U!'CGu!',iY WY)i.^Il
.�— _ —.___.__—..._'_—_
. , . ' �" '�'"' ' � requires o ocrrnif to con-,irvd,c!!er,imorova,demolisn,
_ _ _ _`_ r re,nai;cny sfruci�;e, prior fc rls issuance, also re-
. ' quires fhr�ppli:ant,'ur such permit So;ils o si���d�s4cfc--
� menf ti;af he�s(ite��sed pursuo,it;o 8hepro•risions af th.e
Con'rucfcr's L:censa i.cev jl!:cpPor 9(commencirg wi?h
� � Sec9ion 7SCOj o`UiW,ion 3 cr the Busincss cnd rrofas-
—�- � � sicns leoe;ar�!;oi h:>��,ex��.:r7;Iharalrcm cnd ihe bcsis
`o� ihe �all�geo er.cm�o?:on. .R�rl viol-7ion of SecTion
-- � 7037.3 by any appiiecr.7 for c permiP subje,fs ihe appti-
- con4!o o civif per,oky o`no4 more fhan Fiva hvndred.
. - Jcl!ars!SiO4;..
� � ❑1,cs cwner of•h�properry caill�u tHe.s,or;,cnd
----�— ine structure is r.ot int�snced or cf`ered 5or sd:e.
- �Sec IOb9,6usrness an¢Pra`essions i:oda: 7"he Con.^rar-
• i -----�— For's Cicsn�e,Lcw do:s nof u�ply to an owner ef proper4y
- viFo uuiles c- +n;prcves +tereon, ond vrno dces such
' �-- woric himscl!provided IFr,�such irnprm•en:acts ars no.
�endad cr offered for„ole.rf,iov�ever,thn builo'in�cr
—�---- �--�-- ---- - Improveaient is sa:d wii�nin or,e yaar ui ma�a!e'rion,Ph�
owner-buiide:m�ill he�-."•tho Surdan�?proving Pnaf hc did
. ' noi buri'o'w im}>rore for 1R^�wycse o`sala.)
___ ________ ❑ I,�;o�.vner 6f ihe proper!y,om exclusively con-
I��ciry m�ith:lirr,sed�contrac'or tc cons•ruc7'!-s p-ojeci
------ ----- -- iSec.7Ca4j Evslnass�and Pro`�assons Code: . e Cone.-co-
� � tor�s iicar.sa Law�does nof cp�h,.•90 on oL:�cr�o1 properry
_ ,,._ _._ svho builds or irnproves fhereor„nnd w!;o cortrac!s rcr
� suc!;?rc;atfs�ui;h a contrac4or(s)licenraJ purs�r.n; !o
fhe Cor:tractors 1 icer.se Lew;. '
I c]itl EXf'fY�.DP��n�EY$2C.'___"_— _—"'_
.— , — B$P.C.fcr inis raason _
----- --�-----�- Dnt�-------... ----- �—�--""--
----- . . . � nvvner--. . .... . .. , —'----
iP15PECTOR'S MOYES _