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HomeMy WebLinkAbout0835A WORKERS'COMPENSATIONDECLARATION APPLICATION �FOR PERMIT � I here6y of(irm Ihat I have a cerfificale of consent fo self Insore,or a cerri(icare af Workeri Compensation Insurance, �6A36aC HEATING - VENTILATING - AIR CONDITIONING o�a certified copy thereof((Sec.3800, b. .) r� � O ^1 �r�_� �CE-8181REV.IOi81) .�'. �-. .. . - .. . P�olity No. etU.�� Pp�Y . ... . Ce�rifed copy is hereby fumished. , COUNTY OF LOS ANGELES BUILDING AND SAFETY �Cerrified copy is filed with the cou yb . i peo- � FOR APPUCANT TO FILL IN � � eua�wc ' � ' � ,/ �PR WT OR TYPE ONLY) ADDRESS - Date-��Applicant . IOCAUtt �� NO. iVPE OF APFLIANCE OR EQt1IPMEM . FEE ���FFFRTIFICATE OF EXEMPiION FROM WORKERS' NEAkEST �,I I�� COMPENSATION INSURANCE . CRO5557. (This s�c on nood nol bo tompl�lod ff the work involved 6y ABSORPTION UNI7,BTU DISiRiCT NO. PROCFSSED BY tha p�rmH ti For ona hundr�d dollan(f100)or la��.) qIR HANDLING UNIT,CFM / � �(�(\ � I certify that in Ihe performance af the work for which this . • (O \ 1 ` 0 permit is issued,1 shall not employ any person in any manner - � � so as to become subject to�he Workers'Compensation laws. BOIIER,BTU AVVROVAlS .DAiE INSPE[TOR'S SIGNA7URE Oafe � Applitant � COMPRESSOR,B1U ROUGH "'� NOTICE TO APPLICANT: If, after moking this Certifimfe at VENTILqTION SYSTEM FINAL�� �� � ,L Exempfion, yau should become subjecf fo �he Warkers' � Compensotion provisions of 1he labor Code,you mus�for�h- [VqFpRAiIVE COOLER VALIDATION wi�h comply with such provisions or this permit shall be . deemed revoked. � - FURNACE: FAU_GRAVITY - � . .. LICENSED CONTRACTORS DECLARATION FLOOR BTII � I here6y affirm Ihot I om licensed under provis(ons of Chapter 9 HEATER: SUSPENDED UNIT_ - ��commencing wilh Section 7000)of Division 3 of Ihe Business WAU and Professions Code,an se is in full force and effec � - p,�f � � � � � � 1/l O License Number lia Class �/} ' . - � ' U ConlraUor Da e (� - ' � � H - ❑ I am exempt under Sec . - uVi Plan check fee a N 0.8P.C.for rhis reason PERMIT ISSUING FEE S C� Z Date: Signarore 70TAL FEE � OWNER-BUILDER DECLARATION - PLAN CHECK APPLIUM� Q� � - �hereby affirm ihot I om ezempt from fhe Controc�or's License ► Law for�he following reason(Secfion 7031.5, Business and Nanne Professions Code): ' ' � � � ❑ I, as owner of the property, or my employees with ADDRESS � ages as Iheir sola compensotion,will do the work ond- ��T� TEL.NO. � rhe structure is nat intended or o((ered(or sole(Section �Q��5 p 7044,Business ond Prafessions Code). . - - � - OWNER � ❑ I,as owner oi fhe properly,am extlusively coMractinq �` t�� � � � o$ wUh licensed confroctors b consfruct the projed(Seo- qppRE55 � tion 7044,Business and Professions Code). I • �5 7.7 5 CONSTRUCTION IENDING AGENCY � - CiTY - " - - TEt:NO. � - � - � �� I hereby affirm that fhere is a conslruction lending agency for � • • •5 Z 7 5 c�i the performonce of Ihe work for which this permil is issued CONTRACTOR " � (Sec.3097.Civ.C.�. . �.0�$� }—�� � ADDRE55 .. •�._... .. .. . . . ._'. _ ':'.. _. . ' ' Lender's Name l . . CITY TEL. .�_. .. _ � . � . , Lender's Address STATE LIC. ' I certify that I have�ead.Ihis opplico�ion ond slote Ihaf the IICENSE NO. � � �CLASS �- i! �-� -- � ----� - . ._ _ . _... ._. . ...._. ___. . above informali n is mrrett.I agree lo[omply with oll Counly ordinances on tote ws relating to building cons�roUion, and her by ri epresentatives oi this CouNy ro entei . . . . ... . -. .. . . . � ��... .._ . . .. .". .. . . up ab onedproperty for�P� . � SEE REVERSE FOR E%PLANATORY LANGUAGE _ . . . . . ._ . . .- -- SignoWre o(Applicant or Agen� . Date . - - . . ...� . . . . . _- . . ;• ;' a ;::;: ' 1.: : .. : �. . : OWNER-BUILDER DECLARATION � INSPECTOR'S NOTES i _ � ' - '�' ::. �. , t,_...._ �.,, _ . , '_-'_. ., .._..-...,...,,.... -� `�1�hereby af6rm 7hat I am exempt lrom the Con�raclor's . .. . . .'....."' .'.'.... �•license Law forthe Follovifng reason (Seclfon 703f.5. `. � J ____. . ...__., . .._:..`� _.__. ..._ ...._.. . -' _._ _... .. .. '_ ..... __._ _ .�...._, 8u in z:andPro(essionsCodef:Anycflyorcounfywhlch � . \ t e ,. ,. . . . . . . . . ` � 1 } - - ' requlres o permit Io mns7ruEt,alfer.,,improve,"deiriolish. E � -,— - - - �- � - -� ^ � ' ' � or'repafr any strucfure,yrior-to Hs'7ssoantb,olso re- �� � � � •� . � ._ ___quirestheappffcanlfotsuchpetm�itoiileoslgnedstale- '� -, , �__ . ' , '��_i � ' �. �� � . .. � , - ' �� � menl iFaf he is licensed purauan�ro the provisbps of tbc � , r . � . Contracfora Llcense�low(C6arter�9(commenUng,wifh ' ._�.'.�...,. .L�_.. ��.i.,:�.';��, .� ., . .� ,..'� I _ _ �. . . o(�h.e�6usiness und Pro/es- , . , ., . ...-_._ _ . __-: " .. SecfionJ000)ol Oivisivn 3� � � � , ' "sions�Code)or tlia�he Is exe�mpf�here(rom cnd fhe basis '�. , �, . ' � � �� t �__. _... - - ' � ' ' /or tfie olle�ed exemption. Any violo�lon o1 Secflon . . '___.-_, '..�' _,___'_ _ _ .._ , . � -... �.. � .. '7031.5 6y any opplicanf/or,o�permJf subjecfs�.thebpplf- . ,. .. . . . .._ . . _ _____ _ ._. _ � � onf.fo a civil penally o(,naf more fhdn five,hundred I.__ __._.___.. �� , ... _ _._ ._ _ _... _ � i . _ . _ , do (5500).: . . i ` .. - , ,. . . i .. � Ilan . ; � '�- - � I � -- ---�- ----_-, � "-' ' �, ❑I,as owner oi the property will do rhe wor4,and .... � _.. .. _ . . � . . ..'__ ' . � _ ..._ . . _.__ . � . � ,,., , , : ,, ,_ the structura u nbl iNended or,offered for�,sa�e. .,,, �''. _.. .._� . . .. ..- . �_ .. ___, _. , .._. , �, , ' � � .(Sec.7044,Buslness and Prolessrons Code:�,ihc Conirac- i'�-•� '���- � , . ., for i Utense Low does not apply fo on owner ol proper�y � ���"� -" ' who.bullds or Improves fhereon, and�who does:svch _. __. _ . . .. . . . .. _ . '. _ ' ., �. . ._ . __.�. . � .. ._. � :i i • work himsefl provided iha�such Improvemonis ore nof % -- -- . --� ' �� ! intended or ollerod fo�sa(o.IG howe4er,the building or � . __._ . .. . � , � . Improvement is sold w(thin one year ol camp(etion;fhe ;. . .. ...'. . —.-;�---- �_ -, . . ���ownerbullder wlll have thc burden of proving fhol he did - � � �,` , � � �•� . '_ �nol bu�(dbrlmprove'for�he porpose of sale.J�'�� �� . � ��,'� � _ � ., _ - ❑I,as owner af tho property,am exclusively con- , ' , . + � � trotling with Ilcensed comroctors to construc�ihe�projecr , - - - - - � �Sec:7044)Buslness and Pro(estions Code:7he Confroc- � �� �for i ilcense Law does nof opp�y lo�an owner o1 properly � � - ' - � >� ���-', �who builds or Improvcs}hereon,and who contrcds for � i ' - - such'pro(etts wilh a eonfractor(sJ licensed pursuan�fo . . � ._._.... _ _ . . ___ _ . . ... " . . . . : , ' . . ....�� . . ... .� . .... . .. fhe Confrodors Llcrnse Law)r' '.� .. ��. �. :_. '_ _. � _: '�. .' . . . . .. .. . _ � ..; . I . ... _ .. . .. ._ ._._ __ ..... .._ _. . _._ . �., ,..., l . � _ i .--i I ,�� � '� � I am exemprunder Sec."� � � ' �� '` � � . , .. . . . � � ., . . ,� . , � � � B&P.C.�for this reoson j , i ,_ -__'._ __..___.___ . . __.. . . . . .. . � _ __ ; . .. ' ;,'� " , �. J � �. Date . �. - _ . . . ---- _. . __ - -- .. .. _.. _ Owner , . . , . . �. .. .. , � , , •i -i<_ . .. . . � � INSPECTOR'S NOTES � � - � � � - � � ` . �� �� • • - -.i- . �. � .. � � . . . . ��3 i�� T_�nrLu� iCQ�� � . ,:; ; ; . _ _ .. . _._ _ . _ ,_. . , .. _.. , . _; . - .. _ ., _ � ,