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HomeMy WebLinkAbout1287A �. WORKERS'COMPENSATION DECLARATION �' � � . I hereby affirm ihat I have a ceniiicaia of�o�5e���o self APPLICATfON FOR PERMIT � � �5.��� insure,or a cernRmie of Workers'Compansoiion Insurance, �aAsaac HEATING - VENTILATING - AIR CONDITIONING. or o tertif(ie1d�m(7py lhereof($e^t'.3800,La6.C.) . . ❑ Y 1"1^-I�RP Y �!"�•• CE-BIe(REV.IOi81) -- . .. -- . . . . ,. ' . Polic No an � - � CerrFed copy�s hereby fu�nished. COUNTY OF LOS ANGELES BUILDING AND SAFETY �y� Certified copy is filed with the county�building Inspec• fOR/�PPL��/�1NT T�F����N BUILDiNG '. f1�p _n n (� 1 n r� �11....l '1" tiojcl�of�ment, � �� AOORE55 � yia� YC/•,itrvl` V C,V•� q� � i � (PRINT OR TYPE ONLY) Cj J 1�10..rn(�+���,. � Dafe� ��7�.APPIimn1 LOCALITY �,.2V� . NO. TVPE OF AP7UANCE OR EOUIGMENT FEE .. . �CERTIFICAiE OF EXEMMION FROM WORK S' NEAREST COMPENSATION INSURANCE � CROSS ST. 1� � (ihi�s�ction nMd nof b�compl�f�d ff fh�work inrolvad by AB�RPTION UNIT,BTU oiStaiCr No. .. vROCESSED eY �fh�p�rmit fs for ona hundrod doliars(5100)or bss.J ' � � I certify thm in ihe performonce of�he work for which�his AIR HANDLING UNIT,CFM '. � jD c �� permif is issued,I shall not employ any person in any manner BOILER,BiU so os to become subjeU to the Workers'Compensalion law�. avvaOva�S DAIE INSVECTOR'S SIGNAiURE Dote epplicaN COMPRESSOR,B1U�1)O ROUGH �. NOTICE TO APPLICANT: If, a(fer.mpking Ihis Cerlificafe of VENTIIATIONSYSTEM . F�N�4L � 1 - Exemption, yoo sho�ld become sobjetl to Ihe-Workers' Compensation provisions of the Labor Code,you musl ior�h- evnaORaTivE C(70�ER � ' VALIOATION � wilh comply with such provisions or Ihis permit sholl be � � deemed revvked. � . � � FURNACE; FAU_GR T � ' - � UCENSED CONTRACiORS DECIARATION fLooR BtU �. � I hereby offirm thot I am licensed under provisions of Chopler9 SUSPENDED UNIT_ � �(mmmen�ing wifh SeUion 700p)af Division 3 of�he Business HEATER: wp�� � .. and Professions Code,and my license is in(ull force ond eFfece � � . a � License Number Uc.Class � - - � �a�� V Contraclor �� Date�� .. . - . . � . � � r � � P . . . �,.c 1:'�'�'�-G� U I om ezem t under ec • � B.&P.C.for fhis reason� � Plan theck fee - � � , . �•� �8 ra�Jr 6� � PERMIT ISSUING FEE S U ' • • •8 5.50'� ? Date: O'1.2 7—H 4 Signature TOTAL FEE . � � OWNER-BLIILDER�ECLARATION PLAN CHECK APPIICANT �� � • . I hereby aff�rm thar I am exempt(rom iha Contracmr's license-� _ ► � Law for the following reason(Section 7031.5,Bosiness and Nnh�e . . � , Professions Code): . . ❑ I,as owner of 1he property, or my empioyees with ADDRE55 . ,, . ages os their sole compensation,will do fhe work and CiiV � TE�.NO. �� � the structure is nol inlended or offered for saie(Sec�ion _ • �. � 7044,Business ond Professions Code). ' �' I "�!�� � OWNER �rV1,� r c��/ V . � ❑ I,os owner of the property,am exclusively coNroctfng I`SJI �'t'� . � wi�h licensed controcfors t0[onstrucl Ihe projecf(Se[- N''q�� y,r!j„ i�1 � �, � tion 70<A,Bosiness ond Professions Code). AD�RESS �-T �y�.,� _ .rO(T g'(J_�. �{� ., v' CONSTRUCTION LENDING AGENCY -- CITY �;.{11t��y�1 J� TEL.NO. -� -� � . I hereby affirm that there is a construUion lending ogency for I�t'7� U• - �he performanca of the work for which�his permit is issuefJ - [OMRAROR - � ' . . (Sec.3097.Civ.C.). ' . .. ... . . . . � ADDRES$ ' . .. . � _ � � � . . - tender's Name _ - . . CITY . ._. .IEL.NO. . Lender'sAddress - - �� ',�-� � ����- ' - � STATE LIC. . � I cerfify 7hat I have read this applicotion and s�ale Ihof the LICENSE NO. - CLASS� - . ' _ . . . � obove informa�ion is mrrecL I ogree to comply with all Covnry � . . . ordinances ond Slate lows rela�ing to 6uilding construcfion, , . . � ond heteby authorize represeNolives of this Counry to enter � � ��� _ � �' ' � � � -- � - � ,-- upon ihe above^meniioned properry for inspecti n aurpo es. _ . SEE REVERSE FOR FXPLANATORY LANGUAGE "SIf W1 � - .._ . _ _ . . _ .. . . �f" •� - - , S�gnature of Appli�onr or Agem Dole � � � � ��� - � � � �� _ - :',i,: . . - . . ... OUJNEf:-E3UILDER DECLARATION ' INS�ECTOR'S NOTES � —�— �I heroby o�F rmJhot I om,ex pl fmm Ihe CoNrpctor's .. � . . . . ...-. !;;1,. � Licenso Low for ihe following reason (Set/ion 7031.5. 1' `�� "" '""- ""-� " �'��� '— '�" " �" "�- ' ' - - - � "-�'� "" BuslnessandProtesslonsCodel:Anycityormunlywhich � � ' � - � � - • �requires o permi�lo construct,oHer,fmprove:dvmo/ish. t' '-. �� '. : ' i . ;. :•.' ,. .' ' . . � _ . . E ' ' or repalr any strutWrc,prfor�fa ils issuance, also re � � J ���' qu(reethooppliconiforsuchpesmitfo/Ifeas�gttedstate- . ..' __ 1 ' __._ . _. - � � . � . .. .. � . . . - menf lhaf he B�ficensed pursuar.�to the provlsions ol ihe '� -_ � � � Confrador'slicrnse!ow(Chopter 4(commencing wifh '. . . ........ .,....... ....__._...._..,...._._. �.' '. -.-... . , �' .. ... � .. SecHon 700Df ol Olvision�3 of Ific Susiness and Proles� . ' I � , � "sloni Code)or�hof he is exempf thercirom'ond�he basls ' � � . � . ' � � (or Ihc,alleged exempf�on. Any violdfion'o!�SeUlon � . �.. . � �' ��. ', - � . . . . . - �� , � 7031.5 by any applitanf/or a'permll subjecti the oppli. - - -.._ -� -� ---...._ .,_... _. _. _.. ; � � . .. � '. . .. . �..�. .- .. �. -.._ . _ . ._. . ' ', cant io a c(vil penolty ol�no�.more:�lhanJivc hundred _. �� �, _ ,, . dorras(ssoo�.: _ � . ; r �� � ��J�.�. ���'•'-J`:� ' -� - � �� � ❑I as owner of thc proporty will do thc work,and ��� i y�- \ �, C ` ��� -�- - . � . , . . . . . � the structure is�not IMend=d or offered fo sale.- . �._ •;�S� _ . _ _ �' � ; �(Sec7044,BusinessandProfessionsCode:`;TheConlrac- ".f.�: i i1 . .. . . . . . tor's License!aw doen not apply fo an awncr of properfy �.�., �.. - __'.. � ��- �-��- - �� _ � _ � . � - � .� who bu(!ds or Improves iherean..and who does such � work hlmseH provided t6at zuch ImprovemeNs are not 'U���.�, '`1J-��L3J �- - ��' infcnded or oHered lor sale.If.howover,.fhe bvllding or � � .. .. _ . . � improvemonl Ir sold wNhin one year o(compfetion,fhc , _ � -� - � �- � . owner-6ullder wlll havc Ihe b�rdon of proving ifiaf he did - .. J-� �,:���•L'�'�J� ��. ��t�.f��..`I r`,1�i i�. _}t�,.�. ..' nol buifd or lmprove for fBe purposo ol sale.),�. '� - _ �- ��f,as owner of.1h�properly,am endvsively con- � . . ^ .. � - � trading with licent^d mnhbetors to construcl the�proj�ct . i , � � �� -� -- �-����-- �--- � ' ` .�Sec.7044J Businoss�vnd Professions Code:i6e ConMac- � � � . . . , � � ` . ��ror'z Lfcense law dces nof opply to en oviner of properfy �!�. : • �+ - �� �. � � - - - - �- - -� - --��i ___.who builds or Improves ihcreon,ond who controds for � - ��. .. , � � " , . ' _ , soch projects with a contractor(s)ficensed pursuant�o . -'. � .. �� . , .�..- ..���.�,• ��. . . . . .... .. • �. .--.1hc Controc}or's Lfcensc Law).�. .. ' . -�._ ', �: i '. � '.,i::.. .. . . _ _ . .. __t . .. . .., . .. . . . - , ... - . -_._. . - - --- -. . ' � � � �� '�� I om�exempt�under Sec: - B&P.C.for this reason� ' � � � . . .._. . _ . . .. _. .._.... ' __.. . _. . _.._..___.: .. . � . . . . � � i.. t - . T`. I, . Date ' � .. , �. ,. . : � �'.,_ t ' . . _ . . ... . .. .._' • '. . . . . .. .. _. , .. . .,� . . � i . . . . . . . .. ' _' , . ... ' .. .. . _ . , . . . _ ..Owner , . .. .. . . _. . . � . . .. . , .� , .i . . .... � ... _: . ` �.:�,�..� � � - - . . ... . �INSPECTOR'S NOTES � �� � � � ���- � � - �� . ,... . ` . ..,. , � : - ,�., .. �.. . . . ,. . . , ,. . , . .. . �. .. _,- . -_... . _ _ � � � '. � , . .__._...._,�.. ._ .. ..._ . . _.__. .. .-- �- -- ---. . ____ ._ . - . .r . � ..,_ .. ... _� . �. �-�- ... ...' . . . -. �