HomeMy WebLinkAbout0911A (4) N�.- __ _ _ ,. ��'JORKERS•�oMPENSA,�oNOE«ARAT�oN .� ApPLICATION FOR PERMIT � � � I hereoy aifi+m thol I hove o certificate of consent to self ' irrsure,or a certificate of Workers'Compensation Insurance, jyq3eaC HEATING - VENTILATING - AIR CONDITIONING � or a cenified topy thereof(Sec.3800,lab.C.) I - "CE-B18(REV.10/BI) ' .. .. . . - . i �P❑olity No. Company . . . . Certified copy is hereby furnished. COUNTY Of LOS ANGELES BUILDING AND SAFETY t � Certified copy is filed wirh the county build�ng Inspec• FOR APPLICANT TO FILL IN BU�IDING f r " tion department. (PRINT OR TYGE ONLY) ADDRESS I 1 � � Date - Applicant � � IOCAUTY � NO. TYPE OF APPIIANCE OR EQUIPMENT . FEE � CERTIfICATE OF EXEMPTION FROM WORKERS' NEAREST � COMPENSATION INSURANCE � CRO55 ST. �- a , .(Thfe fotfion na�d nof b�tompl�tod if}he work Involved 6y ABSORP710N UNIT,BTV oisiaiCT No. FROCESSEO BY � tho pormit(s For ona hundrod dollars(5100)or loss.) � r � I certify thot in Ihe performance of the work for which this AIR HANDIING UNIT,�FM �0 'y permil is issued,I shall no�employ any person in any manner BOIIER,BTU ; 50 0510 bP.FOlil subject lo the Workers'Compensolion Low � avraOvnts DAtE INSVEC70R"5 SIGNATVRE Q COMPRE5502,BTU ROUGH ' � Dote V /� pplicant ! �•r��T�CE TO PPLICANT: If, aNer moking lhis Certi mt of VENTRAnOnl5Y5iEM FlNnt .c . - ' � lption,�yoo should become subjeU-to the Wor ers' i i...�npensa�ion provisions of the La6or Code,you orfh- EVADORATIVE COOIER ALIDATION � with comply with suth provisions or this permit shall be • deemed revoked.- � FURNACE: FAU_GRAVITY - � � LICENSED CONTRACTORS DECIARATION FLOOrt � BiU - - I hereby'affirm thoi I am licensed under provisions of Chapler 9 HEATER; SUS7ENDED � UNIT_ - . . '(mmmencing wilh Secfion 7000)ot Division 3 of the Business ' WA« � and Professions Code,and my license is in full force ond effect. • ;_1 q � � . a ,''�^ u�-�-ca O litensa NumberJ��Lic.Class� � -� - � - ' � V OC ContraUor Dale,�_ . . � . . . O �- . ❑ I am exemp�under S . . . . _ . O CJ�.� F{ v � W Plan check fee a ' B.BP.C,for this reason� �' ooie: PERMIT ISSUING FEE S d S�1 f'• • • ` •fi ? TOTAL FEE 1 • o[4,5 O Siqnot�re , . , . � OWNER-BUIL�ER DECIARATION PLAN CHECK APPLICAM � • • •G��Jr O� I hereby affirm�hat I am ezemp�from the Contractor's License , � Law for the following reason(Section 7031.5,Business pnd NAME � � Q 8,� (�—£j$ Professions Code): . ' � ����` I, os owner of fhe properly, or my employees with ADDRE55 ' wages as their sole compensation,will do the work and � � � �y the Slruclure is nol intended or offered for sale(Section ��TV TEL.NO. 17 7044,Business and Professions Code). ��^ -� OWNER �^j ❑ I,as owner of the properly,om exclusively coniracting wi�h licensed contractors to construct the projeU(Ser �`""�� - � � - lion 7044,Business and Professions Code). � AD�RESS CONSTRUCTION LENDWG AGENCY � CiTr - � TEI.NO. -- - I hereby affirm thal there is a mnstruction lending agency for � ' Ihe performance of ihe work for which ihis permit is iss�ed CONtRACfOR �L,O '� ,... � (Sec.3097.Civ.C.). - . . . .. . . . . - ADDRE55 � � � � � �� �� � � ' �� � - Lender's Name CITY . � TEL NO.� � . . _ . . _ . .. . Lender's Address � � � STA7E IIC. I certify�har I have read this appl�mtion ond s�ate�hat the �ICENSE NO. O C�t55 .. . .. . _ .. _ .. _ . ..- .. _. . .. . . above information is corretl.I agree to mmply wirh oll County � ordinances ond State law la�ing to building conshuUion, _ _ � , _ _ . _ . . _ _ , . and re y authorize ie e nlatives of this Couniy o eNer . . � - up n the bove-mentio roperty f inspection rpo s. � ..SEE REVERSE FOR EXPLANATORY LANGUAGE . . _ . .. � . . _. _ _ ... . _ . .. _ . $igno of APPIi<anf o 9m1 D e . . . . . .._ . . . .. . .... . . .__ . . ....... .. .. _. - . . . . , r' ° • • � � - ••� " ` �• �� - ' � IF.SPECTOR'S NOTES OWNER-BUILDER DECLARATI�N " '' , I � ' , �, � ---I hereby affirm that�l am exempt from the Controcfor's j '. i�"..,. ... . �: . ::��.�'. .; ' . ._..__... _.. . _ . . _,___'._' ' 703 ... .,. .,� ..,..,.. . . . License aw ior he followin reason (Sechon 1.5, ; -'� � ""'� '' -" ' ' ��-, , - - " � - � -- � Buslness ond Professions Cade).Any tify or touNy wh/ch � L t r- � l"� �� . ' �,�\.-�� �, � � - � � - � requtres�a permil�fo tonstrucf,olter,improve,demoLsh. � 6 , �' � " ' �---'-�-- - ' -' � -- �- � -- '- '� or repo(r any sfrudure,prlor fo ils Issuonre, also ro- � ,..= � ; �'� -'- -� � � __ _qulree ffiv opplicanf for sucb perml�fo 1Ue o slgnod stafe- E�-------- �` - -- � _, � �'"�---:�-�-----� � � � � �- ' monl thol he fs ficensed pvrsooM to 1he provlsions o!}be '� 17�. , ' �_�„ . ; . Conhacfois�Lkense Law(Chapfer�9(commenctng wftb { .'"'"""'"" - - ' - � �`� ' - " -' � " ' � � �� � � Secflon 7000)o�Orvislon 3 0l Ihc 6usiness ond Proles- i . . . � �� sions�Code)o�thaf he Is'exempf,lherelrom and Ihe�bosis�? i � � ' � . .- '� �� � ' , .for fhe blleged�exemp�ion. Any�viola�ion of Secfion � � '• � � ' . �. , 7031.5 6y any applicanl for a permlt sub�jeds fhe appli• _._.'_.— _ _`__.. __ .'_'. ._ _. . _ _� . . � , . _ _ , ' , - � _ � ---- - - � ,.con}to d clvll penalfy of�no�,morc t6on/ive hvndred j i- --._ . . .�-�-- - ' . .. . �. . ._ � � . , dollo�(SSOOa.� _,� S � .'� ' � � -. '��• " � � ' � I,�os own r qf Ihe ropert,will�do the work,and P Y ' ��- _ , � � � - � � , , �� Ihe�slructure is'no�intended or offcred for sole. . - ��-' �-� - -,--- -�--- . �- , - - �- - -� - ---- � (Sec.7044,8usinessandPro/esslonsCodc:-ifie,� _, . , , � .. `.,}or's Gcensc Law does not opply fo an owncr of f ;erfy -" - �" " �. � � � ,.. who 6utlds or�lmproves Ihereon,'and.who does such , - ___ . � _..._ � . wark hlmself provlded Ihat such Improvements orc no� ' ' - - - fnfended or oi/erod for sole:If,howover,fhe bv!lding o� ' � . .. . � , . , � , .��lmprovement is sold wlihln ono yaa�of.complefion,fbe � ' -�-�� - - � � owner-6mlder wilf have ehe burden ol proving tha!he dld � � Y � . . � �- �no�bWld or Improve for the purpose of sole.} '� �, . - -- - - - � � ❑I,os owner of the property,am exdusivcly con- � , � . � --� lrocting with licenied�eonlroctors to cbnsirucl ihc projecf � �-'---�� �'-- �-- -- �• ��-�(Sec 7044)Buslness and Prolesslons Code:ihe Confrac . . '. . � �-�� ���ior's Llcense Caw does not opply fo on ownefof properly - � - ,-- - ---- �-- --- -� - - - - �-- wha builds or lmproves fFereon,and who confrach for � ' � . , - --- _. . , � � � such proJech wflh o corttractor(s)licensed pursuant ro � . ..-� - .� .. -- .. . .. .. -_-..1he Confracfor's!lcense Low). � �' '� . .,._ . _ __ . _ _ _ _ ._ _ __.__ , . � � � '-`(\'� !'.��� . . � I am exempt under Sec. -'-�-�- . ' ��' . , , ry•�� . � ,�y ' � 8 8 P.C.for this reason ' � _ ;{ ir� 1 ' �.� n� ll � . , � � -- � _ . . _ I _ .. . Date . . . .. � . ' !. 1 '��� f,�� . , . . . . . . � ' � . .� ; , -. . �, � : '. i '�r- , . . � . . .. . - . .�.._._ �, ;. : � �� _ � . . Owner . , � � �� � „ , .." � . ---�_..i:.__. .,-,1 ��. . . . .,, . �. : . , �, � , . 1NSPECTOR'S NOTES -- _ - - � , , . -.. .. . , :. i-._. , , ,._ _,1 r r r. , � ____._..:., _, .. - _. ._. . . .. . .. . .� . C -,\ .. _....__ _' __ _ _. ______ '_... , . .,'�. _ ., � � . . , , , �.. ., ; . . . . ._ _. . . ._' _ __ .__ . _... � . ._ __ . � .. . _ i�, �. � , _ . -. , .. .� .,. _,_ _._. - � . . . � .. � . : , . �..� ��. , . .. . . . _ . .. � , .. ' � , .� . . . � �, .. � .. � ., _..- - --- . ... '.t ._... . ����, , -.,