HomeMy WebLinkAbout1060A W.ORKERS COMPENSATION DECLARATION qppLICATION �OR PERMIT --_X �8 �
I hereby affirm �hp� I have a certificpte of consent�o self
insure,or a certifimte of Workers'Compensation Insurance, HEAYING - VENTILATING - AIR CONDITIONING � �
or a cerfified mpy thereof(Sec.3800,Lab.C.) 76A364C _
CE-818(REV.IOi81)
��Y No.WCrj1S^J9�Company Uni�ard Ins. •
Ce�tified copy is he�eby tumished. COUNTY OF LOS ANGELES BUILDING AND$APETY
� Certified copy is filed with the munty building inspeo- POR APPLICANT T�FILL IN BULLDING
tion depariment. (PRINT OR TVPE ONLV) ADDRE55
Dote 5-29—g7 nppr�o�f 1�n�'ho �Y.,. Tn� �ocnurv Diariond Bar Buildin s A—H
NO. TYPE OF APPLIANCE OR EQUIPMEM FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' �vEAREST
COMPENSATION INSURANCE CRO55 ST.TY'BCt�? 6 O
A850RPTION L1NIT,3TU C'STRIC'No PROCES>ED BY
(Thiz secfion need nof be completed if fhe work involved by .. .. ..,_.
the permil is For one hundred dollars(5100)or less.) �� �
I cerlify thaf in�he performpnce of ihe work for which this ?.IR HANCLING UNIT,CFM �
permif is issued,I sholl not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER,8TU avaxct�A:S osre i�+svecioa's sicNnruze
Dafe Applicanf COMPRESSOR,BTU O OO ROUGH � �.�j
N.faTICE TO APPLICANT: If, after moking this Certificate of VENnIaTiON SYSTEM HNAL �� �
'f lption, you should become subjeci to the Workers'
.apensation provisions of the Lobor Code,you must forih- EVAPORA7NE COOLER V LIDATI�N
with comply wi�h such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITV � '
LICENSED CONTRAQORS DECLARAiION Fi00R a7U
I here6y affirm thai I om licensed under provisions of Chapfer 9 HEATER: SUSPENDED JNIT_
(commencing with Secfion 7D00)of Division 3 of ihe Business � WALL �I v 6���i Y
and Professions Code,and my license is in full force and effe<t 56 R$'�I.�T�S @ 1.•75 9$ �� y
License Number 380543 Lic Closs C-20 , - , YN,.e m • o e 8 �
Rancho Air, Inc 8-31-84 ; _�i 6 8.5 p ,�y
Confracfor Date , 1—
❑ I am exempt under Sec , ���b���'� �
Plcn check fee r5 �
B.&P.C.for this reason �C�,2 f'—�5 7 �
PERMIT ISSUING FEE$ 10 5� �
Do!e:
TOTAL FEE
Signature
OWNER-BUILDER DECLARATION PLAN Ct+ECK APPLICANi
I here6y affirm that I am ezempi from the Contractor's License � - ►
Law for the following reason (SecYion 7031.5, Business and NAM.E
Professions Code):
"���` I, as owner of ihe property, or my employees wiih ADDRE55
wages as iheir sole compensaiion,will do the work and CITV TEL NG
Ihe siructure is not iniended or offered for wle fSeUion
7044,Business and Professions Codel.
� owrvER y�e tlnden Grou�
I,as awner of the property,am exdusively contracfing
with licensed wntroctors to consiruct the pro�leci(Seo- MAIL
tion 7044,Business and Professions Code). .4DDRE55
CONSTRUCTION LENDING AGENCY Cliv Tet
I here6y affirm ihat there is a construdion lending agency ior — � ►
the performance of!he work for which ihis permi�is issued CONTRAQOR
(Sec.3097,Civ.C.1. In •
ADDRESS 1232 W. 9th Street
Lender's Name
Lender'sAddress ��TY U 1.8'nd Tr� ��1�+� 981—�+8�1
STATE LIC.
I certify that I have read this applimtion and slate�hat ihe LICENSE NQ CL455 —
above informotion is<orrecL I agree ro comply wiih oll County
ordinances and State laws relating to build�ng construction,
and ereby auihorize epresentotfves of Ihis Caunry Yo enter
the above-ment� ned properry for inspection p.7urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
'Si�no:re of Ap�l'�cant��q�a����'- L J �� Da�!
tN3P��fi��'� �YE� C7k�i�ER-EUICEaER DEGLARATION
I herety n:Firm�hc: i exempr from ihe ConPracio:'s
-� — - Ucense ia�+.� for r� followin� recsor�, ('Srctto�-� 703i.5,
. . . . . . . . . .. ... .. . . .. - - Eusinesscnc"ra9es=icnsCndc>;:�qnyciryo;rounryw•oici�
__,__ _�.'_._.._—._.._'_'._— 'morave,dc-molish.
re�uira,c�:e�in'rt io r,ohs7uc`,rU�r,,
� ar repoir ony s:ructura, prior fo i' issuoncr, alsn_ re-
� � qu'rres?i�a c�plican7 for suth permr���o iile c slgned s�cic-
- � � ment i!;ct he is litenssd pursuon:tu fi�e provisions cf 4Pie
. ! Conircctc�'s License.o�.v(Cnapter 4(comrriencirg vi�fn
� � � ' � Sece;cn 7u00j cf Uivisicn 3 ef ihc e7usines;and?;ctes-
�--" — sions Codrs)or thot he.is exemp;tFerefrom ar.d fhe basis
. Fcr fhn cl(eged E::em,niion. F ;� viciatian of Sect;o„
-- 703L$by cn;.�app!icant 3or a��rmit sub�je.^Fs fne cppi:-
� nnf fo a civif pena]fy cf.n,o�,more ihnn five hundred
- --- d�uQ,-s rssoaj.
, � . . . . . . ❑'�,es o�vne�a-- e prooery�,�ill do t!-�:,. �rk. ..�.d
'ne sxucrura is no:intcnd�d or of`r�rod for sale.
� . i Sec.744A,Business cnd?'rof2ssicrs�':ode: The��--7c-
for's ticense Law does nof apply'ro an ownar.of c a;fy
wno bvilds or improves ihereor„ ana'who dces such
— — — wo:i<himsaif providcc'!`o�suc.';improvemenrs ore ne,
� �nfended or e4rerad for so(e.!f,i:oweve7,�h vuildinn o.-
�- - imyroven,ent rs sclJ wiiF%n one j�00i c,l comyie!ion, 7`e
owner-buiider wl:l bave ine burdan cI provir,a ihct 4e d7d
- noi 6uild or imprcve far�he purpcsz��cf sa!e.)
_ _ �❑i,qs owncr of Phe property,cro sxclusFaely cor:-
� rrcciing v+ith li�cansed contrc.=ters'o_ nstrecr±he o-ojecr
, _ __ _ 15ac..'04d�Swinc:;s onti Pro/�ssions C,de.7h�Contrcc
. tor's Crc.nse!aw doe�not anply ic cn a�.vner o!progerly
_ _ evho builds or imp!o�r�s inetson,ard wi±o cortra:ts!or
sarh projecis w�th a canfrac'or(s)!"rc��sed pursucrf to
� tbe Contrcc�or's Lrccnse Caov,1.
� i am exemps under Sec. �
— u&p.C.for 4hi,rea.son—
Dn f a�----------------
O�n�r�.._. �
IhSpECTl3R'S PJQTES � �