HomeMy WebLinkAbout1021A (5) WORKERS'COMPENSATION DECIARATION � � �
, I hereby affirm rhat I have a tierfit�cate of�o�,e�,�o se�f � APPLICATION .FOR '���.PERMIT .
iniure,'vr a certificote of Workers'Compansation Insuranca, �aA�� HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof�Sec.3800,Lab.C.) � �
. . CE:8IB�REV.10/811 . � . ... .. . ." . . .-
POolicy No, F 2�-926Company Fairmont Ins. , � � ,-
Certified copy Is hereby furn�shed. - COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy ts filed with the counry 6uiid�ng inspeo- FOR APPUCANT TO fILL IN BWtDwG �
fion[Iepariment. . , (VRIM OR TYFE ONLV) . � ADDRESS`2�� 0 E. Gold oint Pl � ot 1
Dafe 5�29�87 Applicant Rancho Air. I21C. NO. TYPE Of APPLIANCE OR EQUIPMENT FEE ���ITY . �
, �CERTIFICATE OF EXEMPTION FROM WORKERS' NEI1RE57
COMPENSATION INSURANCE ' . CRO55 ST. �
(This s�eflon n��d not b�eompld�d IF fha work Involvad hy AgSORPfION UNI7,87U oisraia No. � reocessco ar
�1h�permlt it for ona hundrrd dolian(SI00)or I�ss.) AIR HAN�LING UNIT,CFM �
I certify tha�in the performance of the work for which this �(O (.V �
�permil is issued,I shall nol employ ony person in ony monner
so�os to become sobjecrto Ihe Workers'Compensofion Laws. BORER,BTU AFVFO`/AlS DATE INSGE[TOR'S SIGNAfURE
� 1 COMPRESSOk,BTU 36+000 ]_O OO ROUGH � �
applicanl s t' �' �
�ICE TO APPLICANT: If, after making thii Cetlifi[a�e oi VENTILATION SYSTEM , FINAL � �fr�jf
Eaemption, you should become subject to Ihe Workeri �
Compensation provisions of the Labor CotJe,yoV mu5�forih- EVAPORATIVE COOLER � VALIDATION
wfth comply with such provisions or ihis permit sholl be � � � .
CJeemecJ fevokeCJ. . FURNACE: FAU�_GRAVJ7,��_ lo 00 ,
- � �LICENSED CONTRACTORS DECIARATION �- FLOOR BTu bY5 �
� I hereby aff�rm tha�I am licensed under provisions of Chapter 9 SUSPENDE� � UNIT_ -
'(commencing wilh Section 7000)of Division 3 of the Business HEATER: WA��
� dnd Professions Code,and my license is in full force and effecf. � - - - ==� O 2 S A r
11 Re isters @ l. 1 2 }t. . e e e g O
License Num6er � 38OS�3 Lic,Closs C-2� - � � � , • V
Rancho Air,Inc. 8/15/87 � • °49.75 0
.Contractor Date �o =
❑ I am exempr under Sea a 4 9,7 5� W
Plan check fee � 0�t 2 d�8 6 �
- 8.8P.C.for this reason� ' . PERMIT ISSUING FEE S 10 0 � ' Z
Dote:
Sgnature TOTAL FEE ; ly
� OWNER-BUILDER DECLARATION PLAN CHECK APPIICANT � ' ,
I hereby affirm lhat I am exempt from�he Controttor's license , � �
low for.the following reason(SeUion 7031.5, Business and NAME . .
,�'"�essions Code): � � � , ;
u I, as owner of ihe property, or my employees with /+DDRE55 . ,
wa9es os iheir sole compensa�ion,will do the work and .
fhe sirocWre is nol intended or offered for sale(Section CIN � TEL.NO. � .
7044,Business and Professions Code). � � - - � - '
OWNER
❑ I,as owner of the property,am exdusively tontracting � u �
wifh licensed controcfors to conslrucl the project(Sec- ��� �
fion 7044,8usiness and Professions Code). ADDRESS 10 1+ Parkview Drive 201 . � �
CONSTRUCTION LENDING AGENCY � � CITY - , � TEL NO. � � � , �
I hereby affirm�hat there is a constroUion lending agency for — .
fhe performonce of ihe work for whith fhis permit is issued � CONTRAROR - - � � -� '
(Sec.3097.Civ.C.). ' . .. � . '
..... _ _. ,._ ... . .
lender'a Name ADDRESS � l•z 2 W. th St. - � - ; . . f � . .. _
arv U land re�.No. $1 —4801 _
Lender's Address � � - -
I cerlif thof I hove read this o lication and slate Ihat the _ STATE � LIC. �
Y PP LICENSE NO. D � � QASS - C�2O . . .. ... �... . . - . ,
above informa�ion is mrrect I agree to comply with all County � �
ordinances and State laws relafing fo building tonstrottion, � _ � ' ' ��
and hereby aufhorize representatives of this County to enfer , � - � . � � - � � � � � -
�on�he obove-m^eroioned�roperfy for ins edion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
y� �XX� .��S ��D _
Signarore ol Applicani�or Aqen� Date . . . ... . ' . . . . . . . ,
'� . . -' OWNEP.-IIUILDER DECLAF£ATION '' '
IN3PECTOR'S NOTES . _
� - �- I here6y offirm tho�I am ezempt from�he Conhoclor's
. � �-� - � `� ��"-�� License Law for Ihn following reason (Senlon 7031.5,
; .....__.. __..___ ..._.. �., ..... ...-_._. .___.... _._ ..._..._._._ .._._. . _. ,_....... .._.__....___.:. _.. EusinessandProfessionsCode):Anycityorcovnfywhich
� �� . .� � ' � � � � � �- � � � requires a perml�lo constroct;ofter,Improve�,demolish,
i..-� �---- ..'. .��... .. �. : . ' �..;�.� . . -�'. . - � .'... ; . or repalr any slrutture, prior fo!fs fssuance. also re-
. i •-� � . - , � � � ._ � qolres 1he appliconl/or such permii to flle�v slgnod smte-
.. �...__.. :� _ ._. � . . ' . .. � .. . . . .,, ,� ..
t �- � � ... � � � � ' � menf fhai he iz Ucensed pursuanf ro the provlslons of�he
y . . . � Confrallor's License Lew(Chopfer 9(mmmoncing wifh
� .. ...___.._._...__ ..__..�_ ._.._....._ __._.... . :-�...' . � - . -. '� Secfion 7000)of DiNsion 9 0/Ihc 6usiness and Proles-
. . �........_... . .. . . .
� i - � � �sions'Code)or Ihaf he Is exempl therelrom and ihe basls
'� �, ' �. ��� _ _ __ ._ _.-� - �. - ' �- , � lor Ihe alfeged exemplicn. Any violalion o('$ecNon
� �- i � , . . , . 703L5 by ony appticaN for a permit subjec�s the�appB-
:. •
�'-- - �------ . ...__--��---_--._ ._ ..
� , ... . . � „ �. - �.. --4 ._-- _ .. '� conf fo a.civil;penofly of nol,more,ihan fivo hundred
���- � --_.. .. .-- -- ._ . ; . _. .... ' - . . do aQ S f h n 'I d d
� n s(soo).:
. I . _ . . . ' � _ � �� � . ' ._.. �" ' �. . I,as owne o t e ope wi o Ihe w
. . ` _ '._ -' . .__ _ _ ;_ , r
pr y I or�on
--- - "�- ;� _. �" , , , . �, structure is not intended or offerad for sa�e: �
� y `^ , , �hec.7044,Duslness and Proleszions Codc: �Thc C, ,.roo
, �,_.. . ,. �-Se . . ,
., . , , � . ��for's License[ow does no�apply fo an owner ol property
� �,----= � � � ; _ � � � � '�� � ,. -who builds or�fmproves lhereon,�and who does,such
.. _ . work hlmsclf provlded fhvt such Improvemenfs�ore na�
i ' - - ' � - � � intended or'olfered lor zafe.f/,howevcr.�he bvtlding or
; ._._ ._.. _ . . Improvemanf Is sald w7Ltiln one yeor o/complefion.�ihe
; '-- - --� �-- -�� �- � ' : � � owncr•boflder wl1l have Ihe 6urden o/proving/hof ho did
� r � � - � • nor bulfd or Imprave for}hc purpose of sale.) �����-���� �
. i � ' � � . . . � � .
� ' - - � � . ❑I,as owner of the property,am exclusively con-
� .. � . • --`� trauing with licensed coniractors to conslrLu the�project
� � � � - - - � .(Sec.7044)Buslness and Profestlons Code:7he Confrac-
� � � � � � - - �tor's License!aw docs no}apply to an owner of prop_erty
. � , - -� - - - � who bullds or Improves lhcreon,and.who confrocfs(or
� . _ � � � ' � such projecis witfi a conlractor(s)licensed pursuanf�o
. - . _ ._ . ... . _... .... ... . - . . . .. . -�fhc Confracfols llcensc Low). . . .
i
_ .
� I am exempt�nder Sec "
B&P.C.for this rcason
--- _--.__ . ___ _ _._. ..._ _ -
_ � . Date � ' . . . .
' ---- . _ ' �_ ' Owner . .
_. _. _ __. _ _ . .: _..;
INSPECTOR'S NOTES
c)r,� c.:1`�:; .r���.�r� }.,a.^,.��r�