HomeMy WebLinkAbout1370 VALLEY VISTA (27) WORKERS'COMPENSATIONDECLARATION , � � �'ATION �OR PERMiT �
I hereby affirm that I have a cartificate of consent to self � �/`�• • --r�
insure,or a certificate of Worke�s'Compensotion Ins�rance, �bA�� HEATING - VEIVT{lATING - AIR CONDITIONING
or a certified copy thereof(Sec.3800,Lab.C.) CE-81B(REV.10/81)
��WC�-lfi2-030337 Oampany I ihar y Mutnal
Certified copy is hereby fu�nished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
O Certified copy is filed with the c t building spec- FOR APPLICANT TO FILL IN BUILDING
tion department. � (PRINT OR TYPE ONLY) s1DDRESS 1370 Val ley Vi sta 5111tE #2
Dote 1/1/A9 APPlicant � IOCAIITv Diamond Bar
NO. TVPE OF APPIIANCE OR EqUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEnREST
COMPENSATION INSURANCE CROSS Si.
(This s�ctlon naad�rot bo tomplalod S fho work larolvad by A850RPTION UNIT,6TU DISTRICT NO PYOCESSEO BV
1ho permit 1�for one h�ndrod dollan(5100)or loss.) qIR HANDLING UNIT,CFM /Q �
I certify that in the performance of the work for which this L
permit is issued,I shal�not employ pny person in any manner
so as fo become subjecl to fhe Worken'Compensolion Laws. BOILER,BTU qvprtpvqis Dnre INSPECIOR'S SIGNATURE
Date oTplicant CW+�wte55oa,etu ROUGN
��r1TICE TO APPLICANT: if, afler making this Certificate of vEMILATION SYS7EM FINAL
[` nption, you should bewme subjed �o t6e Workers'
4..npensation provisions of the Labor Code,you muet forth- EVAPORATIVE COOLER YALIDATION
wifb comply with such provisions or this permit sholl be
.daemedravoked. FURNACE: FAU_GRAVITY
IICENSED CONTRACTORS DECLARAT40N FLOOR BTu
I hereby offirm�hot I am licensed under provisions of Chapter 9 H��R: SUSPENDED UNIT_
�(commencing wi�h Section 7000)of�ivision 3 of the 8usiness � wALL �
ond Pro4essions Cade,and my license is in fuf�force and eReci. - >
7 Air Inlets b Outlets a
license Nomber 307(140 Lic.Closs C-20 S _ �
�,� �` u
Controctor Air Systems. IfiG. Date � " �
� tl ;, . . . � O
I om exemp��nder$ec, d 3I 4 �
Plan check fee � � y c c 7._ a
w
B.&P.C.for rhis reown PERMIT ISSUING FEE$ �p .a� z ... - z
Date: ' `
. TOTAL FEE
Signature 1 �. I E•—i. ;.
OWNER-BUIIDER DECLARATION PLAN CNECK APPLICAM
I hereby affirm ihat I am exempt from the ContraUor's License � ,
Law for the following reasan(Section 7031.5, Business and NAME
Professions Code):
1, as owner of ihe properfy, ar my employees with AD�RE55
�_ woges aa iheir sole compensotion,will do ihe work and
the strutture is not intended or offerad for sale(Seclion CtTY TEL.NO.
7044,Business and Vrofessions Code).
OWNER Cabot, Cabot, & Forbes
❑ I,as owne�of the properfy,am exclusively contracting
wi�h�icensed con�ractors m consiruc�the projed(Sec- ���
tion 7044,Businass and Professions Code}. ADDRE55 911 Wi lshire Blvd. 1�1�
GONSTRUCTION LENDING AGENCY ptv LDS Angeles, 90017 TEL NO.
I hereby affirm that there is a mnstruction lending agency for �
the performonce of the work for which this permit is issued CONTRACTOR A71' Systems, I11C
(Sec.3097,Civ.C.�.
AODRE55 1454 S. Manhattan
tender's Name �
Lender's Address CQV Ful lerton CA TE��r'1O� 714/992-4490
f certify that i hove read this applica�ion and s�ate that Ihe SCENSE NO. 3O�OOD ��A� �-2�
above informotion is crnreci.I agree lo tomply wifh all Co�nty
ordinantes ond State lows relating to building consiruction,
and hereby authorize represenmtives of this Couniy ro enter �
upo t 1 a ve- mioned property for inspecGon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
11/1J88
Signol�re of Applicanr or Agent Do�e
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