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HomeMy WebLinkAbout1011A (5) WORKERS'COMPENSATIONDECLARATION APPLICATION ,FOR PERlY,IT � I hereby affirm thal 1 have a certifimte of consent to self . iniure.-or a cernficate of Workers'Compensmion�nsu.once, ��3�� HEATING - YENTILATING - AIR CONDITIONING or p Certified topy Ihereof(Sec.3800,La6.C.) CE-818(REV.10/91� - ' -- � ' Ooy No. F 21926comPa„Y Fairmont Ins. Cedified copy ts hereby furnished. COUNTY OF LOS ANGELES BUIIDING AND SAFETY O Certified copy is filed wiih�he counry building inspeo- FOR APPLICANT TO FILL IN BUILDING ,. IiOnfJep�rfmCnt. . . (VRIMORTYPEONLY) ' ADDRESSQ7{Iy�{ E. Gold oint Pl Lot 16 Dare 5129�A� Appliwnt �R&T1Ck10 Air, Inc. � , ��+��TY � � NO. TYPE OF APPIIANCE OR EQUIPMEM�. � FEE CERT�FICATE OF EXEMPTION FROM WORKERS' � NEnREST . GOMPENSATION INSURANCE , � cROSS ST. , .(Thl���cilon nead nof ba compleled 1i iho work Involvvd by ABSORGTION UNIT,BTU DRia��T Np, pROGE5SE0 BY tha parmk ts for one hundrsd dollan(f100)or lo�s.) q�R HANDIING UNIT,CFM � ' � I ceitify Ihat In Ihe performance of 1he work for which Ihis - !� (�di� permii is issued,I sholl nof employ any person in any monner BOiiER,67u � so as to become subjetf to the Workeri Compensolion Laws. . aavaovais OATE INSPECTOR'SSIGNA7URE � 1 COMPRESSOR,BTU � a7��nn ZO O ROUGH � �� {�.� � °PPlimnt � . r ICE TO APPLICANT: If, aNer making Ihis Cer�ificate of VEMICATION SYSTEM . flNAI � �- � rExemption, you shou�d become subjecl lo fhe Workers' Compensation p�ovisions of�he Lobor Code,yoo musf forth- evA�enTivE COO�ER ' V LIDATION with comply with such provisions or�this permil shall be . deemed re�oked. � 1 FUORONR CE: FAV eTu GR$v�v�� 10 0 � � LICENSED CONiRACTORS�ECLARATION . � �I hereby offirm�ha�I am licensed under provtsions of Chop�er 9 HEATER; SUSPENDED UNIT� - ' ' � . "(commencing with Secfion 7000)of Division 3 of ihe Bosiness - WA0. , . ' ond Professions Code,and my license is in full force pnd eHect �" . � ' �, �� O�.� A a Re isters @ 1.75 15 5 License Number 3805k3 Lic.Closs C-20 � �s.• e + •$ O � eo�r,oc+o. Rancho AiraInc.oare 8/15/87 I A•4Q25 � ❑ • . � I pm exempl under$ec. �e U�r 5� �++ Plan check fee . a B.&P.C.for Ihis reason� � �' PERMIT ISSUING FEE S 10 0 ���0'-8 6 ? Dote: Signawre T07AL FEE 1y( . OWNER-BUILDER DECLARATION FLAN GHECK APPIICANT � '' I hereby affirm Ihot 1 om exempi from the Cantrattor's License � �. law for the following ieason(Settion 7031.5,Business ond Nn6tE � . � � . : -��`essions CodeJ: � {,_I I, os owner of 1he properiy, or my employees wilh A�DRESS � ' . woges as their sole compensation,will do the work and CIiY � � TEL NO. ihe s7rvclure(s nor iNended or offered for sale(Sec�ion � 7044,6usiness and Pwtessions Code). - � . � ' OWNER ❑ I,os owne�of the properfy,-om eadusively coMmtting � with licensed coNrac�ors lo mnstroU�he projeU(Seo- �'�� � � -- � �. � tion 7044,Business and Grofessions Code}- AODRE55 Q �} D ' 201 ' . . CONSTRUCTION IENDING AGENCY , Ci7Y ovina � rE`."o.- 6 - 41 . � I hereby affirm Ihaf ihere is a tonstrudion lending ogenty for ihe performante of the work for whith Ihis peimif is issued CONiRAC70R Rancho I�1T IriC. ,. � � (Sec.3097,Civ.C.). - . . - . . . . . . ADORE55 '2 2 W. YI St. . . . . . ... � . . . -.. Lender's Name I� . CITY TEI.NO.- 1�N Ol . ... . . . . . . - .. . _ Lender's Address � � I certif ihat I hove reod this o ticotion and sfa�e Ihot 1he 57A7E L�C. � � y pp UCENSE NO. 1{ QASS —2O . above infarmation is correct.I ogree�o comply wilh all County � ordinonces and Stote lows relo�ing to building construcfion, _ .. , _ ,_, . _ and hereby aufhorize representatives of fhis Coonty to enfer . � � �g°r��he°6°ve-mentioned propery(or iry�pec-rio purposes. �� _ „$EE REVERSE FOR EXPLANATORY LANGUAGE . _ , . . .. ��s�t.._� ��— �I�� Signai�re ol Applicanr or Agenr � �aie . . . . . . . . .. . . - . ...� . .. ...�. . .. . .:.. . . � . „ � . _ . . .;. . ... . ., - _ _. � '�' ' � IHSPECTOR'S NOiEs OWNER-6UIlDER DECCAf£ATION', - �-�-I�hereby off(rm ihar I�am oxcmpt from the Conlractor's � ' ���� "� - -�'� � license Law for�the followine��reason (Soc�ion 703L5, ,.,.__........___.. .__..._ _._.,._.._.. _. _.. '_.. .'. ._... __._.... .. � '- "-'�""���-"` " �--" --' '� '"' '�-"- - BozlnessendPro�essionsCode):Anycifyorcoumywhicb � . �� � � ' - � � -� �- � - � - requfres�o permit lo cons�rocl,ol�er,Improve,demolish, �� �� � "- �-- � -" �-" or re i an sfrucfure, rlor fo lfs Issuance, ofso re- i l•,-".• �� . .. � � : .� - .. ._9ulreslheapplimnf_/orsuchpermlllolilc.'asfgnvdsfafc- -.--.--... .....�:�.�. .. _,�_ ._.._. .� � -. - . ' . - : . � ment fhaf 6c la Ilcrnsedpursvent to ihe provlsfons of Ihe � `_ �� ` �. ConMac�or's.Ucense Law fChopter 9(commencing with �.-........... .....- ..'.. �..... ...... - i ..__ ..... _ .��. . . : � `, SecHon 7000),0(Divizion 3 cf f6e BusMess and Profes� � � � .' , � � ' ��dions'Code)or lhof he is exempf therelrom and 1he basls ' �� � " � � ; for fh� �olfeged ex-emp�ion..Any Jiola�lon of Section i �:..;, � .f ; ---- '__ � � . . . . '" _..:. � �"7031.5,6y�uny appficant Ior o permit subjecis 1he oppli- ..-_- __ . . . , . .-_-.__- . . _. . . . . .. . - . � . .._. .- --. -.. .-..-. '. � ..mN b a,civN.penolty of not more'Ihan livo hundred . . . . . . ,. . , . ____ ._-_..___.-,-_ _ . _.__..._... . _ . � , . . . .. , , . ; do . _._ _ --._ ---_• , , 1 ❑ISS�OOowne of ihe o crt wil da the . � ..�: .��.� . . :. �. . .. ....� --�- ,. . ... ... .. .. .- -� "�helstruUure's nor in�end=dror.offered for ealewo rk�and � � �� ��' �� � � �' � - � �� (Sec.7044,Business ondProfessfons Codr. The C�...rac _.. _ � _ .. .. � .. � � . . . . . , �tor's Utense law daes not cpply fo an owner of property .� �, .�� ,.. . .... � ,. ���-� � � ._ __ . .: • � ' � �� who 6uilds or Improves fhereon,ond who does such ' � ��� . ... ., . . ._ _ � � work hlmsel(provided fha�such improvemen�s are not � - � '� -�- �- � - "� �_. � ' : infendod�or offwed lor so(e.d,howwer.Ihe building or �__.._ . . .. -.. ... � � ' , � --. - - .-..- ... .. .. � .. .improvemont Is sold wlfhln.ane yaar of compleffon..�he ' � -- ------ -- �- �' ' ownenbuilder wlll hwc fhe 6urden o�proving lhot he did ' ' ' , . _ . � .. . , � ��nol buifd or Improve for the purpose o!sole.) � � •� _.. . . . . . � . - -�- � � ❑I,as owner of Ihe property,om exclusively con- � - � , '. � � -�-'� �-troctinq�wilh licensed coniracten�lo construu the project - -� --���� � �-��- � - -�-� -- - �� - �� (Sec.7044)Euslne;s ond Prafessions Code:iRe Controc- � �� � � ----� tor's License[ow docs not apply fo en owner of properry � � � -���- - �-�- - - - �- who builds or Improves thereon,and wha.mntrdtls 1or � - � . ��� ��' �� such projects w(tfi a contraaor(s)licensed pursuon�fo . __..... .... _ _.. .. _ , , ..,.. �. � - - , - -the Controctor's License lavQ, � . .._.__ .. _ . .. . _ � � � � � � I am exempt�nder Sec. � - B&P.C.�for ihis reason '� ` � �. ._ _- ---� �-- --- —-- � ,.. . . ,. . . , . , . . _. __ ..----- —�- .. . . � • - .. . . . . . � Data ' � -.t� - . . . . -. ,_ � _. ._-...--- � � � ' � ' ' ' Owner , . . � ;.. .. .. , . , � � -- � �� � - . . , . �. . . ._ INSPECTOR'S NOTES . -._. -----._ •"�. ...� . .. ' � _ � ; � 1 . . . . . � : � . .. . �. :: .,, .. .. . .,.. ._ , ; . . �.,. � . .5� . , � � �)r,.�.-���'71�t'J c.i4�J�•.il. L�A�-•.6Ji��� .