HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (58) WORKERS'COMPENSATIONDECLARATION qpp`OCATION FOR� PERMIT
I hereby affirm tha' I have a certificate of consent ro self
insure,�or p certifimte of Workers'Compensofion Insuronce,
o�a cer+it�ed copy ihereof(Sec 3800,Lab.C.? �6aaeac HEATING - VENYILATING - AIR CONDITIONING
' CE-818;REV.�0�811
P❑oll<y No. Company
Certified copy�s hereby;u�nished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
' � Certifed copy is filed with the county b�ilding inspeo- FOR APPLICANT TO FILL IN BUILDING
'� tiOn Jepa�tmBn�. ;PRINT OR TYPE ONIY) AOOkE55
• Date Applicant LOCALITY
ND. TYPE OF APPLIANCE OR E�UIPMENi FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAaEST
COMPENSATION INSURANCE CRO55 ST.
ABSORPTION UNIT.61U �ISikl.^.:NC. FROCESSED 9� '
(This section need nof 6e completed if fhe work involred by
the permif is for one hundred dollars(�500)or less.) +
I certify that in ihe performance of�he work for which ihis A�R r!AND�iNG UNI7,CF�d j '
� permit is issued,I sholl not employ any person in an/manner
so as�o become s�bjed to 1he Workers'Compenspfion Lqws. BOILE2,BTL n=veovHi= onre f�n;SFec�oa55iGNnTuee
��Dote Applicanf - ' ' COMPRESSOR,eTU �OUGH
NOTICE TO APPLICANT: !f, after moking rhis Cerirficote of VENiI�AT!O�u SYSTEM , , FINA�
� Exempfion, you should bewme subject ro the Workers'
Compensation provisions af ihe Labor Code,you must forth- EvnPORAi:vE COCLER , VALIDATION
with comply wilh such provisions or this permit sholl be
deemed revoked FU4NACE� FAU G4AvlTv
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby aHirm that I am liwnsed under provisions of Chapter 9 SUSPENDED UNIT_
(commencing with Section 7000)of Division 3 of the Business HEATER: WA�� �
and Professions Code,and my license is in full force ond effed. {,�
v
License Num6er Lic Closs ► �
ii
� Contractor Date
y
❑ I am ezempt under Sec �
Plan check fee J q p x
B.&P.C.for this reason � ^� ���� P"� �
PERMI7 ISSUING FEE S , t � y,,� :. �
oare
YOTAL FEE � �
Signature � t''�� :i,E.�i�,.
ONINER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm thai I am exempt from the Contractor's License ► a.'b,: t;::_ �„
" Low for the following reason (Section 7031.5, Business ond NAME
Professions Code): , a.. _„ , , ,..
QI, as awner of the property, or my employees wiih ADDRESS
wages as rheir sole mmpensa�ion,will do the work ond
ihe siructure is not intended or uffered fo•sale(Section OiY ie�.h0.
7044,Business and Professions Code!. O'�V��ER
❑ I,as owner of the property,om exdusively coniracling
with licensed conirodors ro construc'!he proi �;Sec- �"�"�:
tion 7D44,Bus�ness and Professlans Codej. ADDRESS
CONSTRUCTION LENDING AGENCV Giv iEL NO_
I hereby affirm thot there is a ccnstrudion lending agency tor ,
the performance of the work for which this oermit is issued WN7RAC'02
-(Sec.3097,Civ.C.).
ADCRE55
Lender's Name
CITv TE_ NO
Lender's Address
S1ATE iIC.
I certify ihot I have read this applicotion and state fhat ihe LICENSE NO. CLA55
a6ove informotion is corred.I agree io comply with oll County
ordinances and State laws relaring to 6�ilding c nstroction,
and hereby authorize represen+o+ives of this Cou�ty to enter
upon the above-mentloned properry for inspectlon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
5ignar�re of Apolicarf or Agcn, Da�e . ^
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