HomeMy WebLinkAbout1817A%'-'OR KERS'COMPENSATION DECLARATION
7BA364
FOR PERMIT
1 hereby affirm that I have . certificate of consent to self
CE -SIEC (2 -BO) .. .APPLICATION
acure, or certificate o(Workers* Compensation Insurance, of
HEATING -VENTILATING -AIR CONDITIONING
copy
a certified copy thereof (Sec. 3800,/LJ.•y�_J
L/C Certified copy is hereby furnished.
``Certified
COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑''
copy is filed with the county building inspection
department.
FOR APPLICANT TO FI LL IN
BUILDING
ADDRESS/
.Date Applicant
(PRINT OR TYPE ONLY)
Il
Cl RT[FICATE OG EkL:'s1PTION FROM WORKERS'
S'
NO. TYPE OF APPLIANCE OEQUIPMENT FEE
_
COMPENSATION INSURANCE
NE
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(This section nfCrinot be completed if the work involved
-
ABSORPTION UNIT, BTU
by the permit is for one hundred dollars (SIOO) or less.)
_
OIS I.ICTNO PROCESSED RY
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I certify that in the performance of the work for which this
AIR HANDLING UNIT, CFM
�
or—'/
7
permit is issued, 1 shall not employ any person in any manner
1I
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so as to become subject to the (Corkers' Compensation Laws.
BOILER, BTU I
1—
'
APPROVALS DATE
INIPECTC •'S SIGNATURE
U
Date Applicant
COMPRESSOR, BTU
EL
NOTICE TO APPLICANT: If, after making this Certificate of
_
ROUGH
y
Exemption, you should become Subject to the Workers'
VENTILATION SYSTEM -
FINAL
Z
—
Compensation provisions of the Labor Code, you must forth-
- -
-
with comply with such provisions or this permit Shall be
EVAPORATIVE COOLER
VALIDATION
deemed revoked.
FURNACE: EAU_ GRAVITY—
RAVITYLICENSE.DCONTRACTORSDECLARATION
LICENSED CONTRACTORS DECLAR ATION
FLOO R - BTU_
1 hereby affirm that 1 am lice used under provisions of Chapter
HEATER: SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Busi-
WALL
efSS and Professions Code. and my license IS in full farce and
effect.
O
License Numbe(]Lic. Clas/sjyt�I��./�(`
-
. Contrac � yyJJ
Lensing
Elam e pti fr(u requirements as I am a
licensed architect of a registered professional engineer
Plan Check fee 25% Of above.
acting in my professional capacity (Section 7051, Bus-
+ _ -•
-- _
ineai and Professions Code).
PERMIT ISSUING FEE S`.
Lie. or Reg. No. Data
TOTAL FEE
HOME OWNER -BUILDER DECLARATION
PLAN CHECK APPLICANT
181.7A
1 hereby affirm that I am exempt from- the Contractor's
NAME ..!
.e Ie
' License Law for the following reason (Section 7031.5,�Busi-
mess and Professions Code):
ADDRESS
.I 1 P v 0
❑ I, as owner of the property, will do the work and the
1� 0
-
structure isnot intended or offered for sale (Section
CITY TEL. NO,
;C 2 3 5 0
7044, Busines, and Professions Code).
OOWNER
[, as ownar of the property, am exclusively contracting
with licensed contractors to construct the project
MAIL
(Section 7044, Business and Professions Code).
ADDRESS
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction lending agency
CITY TEL. NO.
-
for the performance of the work for which this permit is
I (Sec. 3097, Civ. CJ.Lender's
Cissued
Name
AOD—i
;IT
Lender's Addresv
t
CITY ip _T.. ��E L.Nv�1�`,,
-
1 certify that I have read this application and state that the
STATE LID.
above information is correct. I agree to comply with ill County
LICFNSF OG CLASS
ordinances and State laws regulating Hearing,Venula Ung and
Air Conditioning, and hereby authorize representatives of this
Slit. RI;V6RSIi FOR EXPLANATORY LANGUAGE
to enter upon the above-mentioned property for
npurp�se/s.�+/,/J//�f�/J�
���=—mil
Date
INSPECTOR'S NOTES
INSPECTOR'S NOTES ,
OWNER -BUILDER DECLARATION
- I hereby affirm that 1 am exempt from the Contractor's
License Law for the following reason (Section 7031.5,
Business and Professions Code): Ary, city or county
which requires a permir to construct, alter. Improve,
demolish, or repair city structure, prior to its issuance,
also requires the applicant for such permit to file a
signed statement that he it licensed pursuant to rice
provisions of rite C'ontra?tors License Law (Chapter 9
(commencing with Section 7000) of Division 3 of rhe
Business and Professions Code) or that he is exempt
therefrom and the basis for the alleged exemption. Any
violation of Section 7031.5 by any, applicant for a permit
subjects the applicant to a civil penalty of not more than
five hundred dollars (5500).:
❑ L as owner of the property will do the work, and
the structure is not intended or offered for sale.
(Sec. 7044, Business and Professions -Code: The Con-
tractors License Law does not app{v to an owner of
property who builds or improves thereon, and who does
such work himself provided drat such improrements
are not intended or offered for scle. If, however, rite
building or improvement is sold within one year of
completion, the owner -builder will have due burden
of proving that Ire did not build or improre for the
purpose of sale.)
❑ 1. as owner of the pioperty, am'exclusively con-
.. - - meting with licensed contractors to construct the project
($vciioh. 7044; Business and Professions Code: The Con-
tractor's License Law does not apply to an owner of
property who builds or improves thereon, and who
contracts for such projects with a cwuractor(s) licensed
{ pursuant to the Contractor's License Law).
i am exempt under Sec.
B & P.C. for this reason
Date
Owner