HomeMy WebLinkAbout1370 VALLEY VISTA (58) WORKERS'COMPENSATION DECLARATION qpp11CAT10N FOR PE.RMIT. �
I�hereby aifirm that I have a teriificate of consent fo self
insure,or a certificata of Workers'Compensation Insurance, ���� HEATING - VENTIIATING - AIR CONDITIONING
or a certified cop fhe�eof(Sec.3800,Lab.C.) �_818 REV.10i8�
WC2-162-�130337-087 � � ' - --
P❑ol�icy No. Company Lihar� Mufiial
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAfETY
� Certified copy is fi�ed with the co ty u' ing inspec- F�R APPLICANT TO FILL IN BUItDiNG
tion departmenf. (PRINT OR TVPE ONLY) ADDRE55 1370 Val le VlSta Slllt 1
po�e 1/1/89 p�Plicanf . LOCALITY Diamond Bar
NO. 1YGE OF APPIIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTI N FRO WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This wcNon noad no!6o complotod if 4ha work iovolvvd by ABSORPTION UNIT,BTU DISiRIC�NO „ FROCESSED BY
11ro pormil is For o�ro hundr�d dellan(s100)or lys.) AIR HANDUNG UNIT,CFM
I certify�ha�in the parformooca of tFe work for which�his lQ
permit is issued,�shal�no1 employ any person in any ma�ner gpILER,BTU
so as to becoma subjad to the Workers'Compensafion laws. ncvqoVnLs DAiE iN ECTOR'S SIpfJA7URE
Date Appll[aN COMPRESSOR,B7U ROUGH T-��, /�-���
NOTICE TO APPIICANT: If, after making this Certifica�e of vENTiWTiON SVSTEM F�NAL r
� nption, you shauld became subjed ta ihe Worked
.ipensotion provisions of tha Labor Eode,yoei musf forfh- EVAPORATIVE COOLER VALIDATION
with comply with such provisions cr thi: permit shall be
deemed revoked. FURNACE: FAU-GRAVIiY
LlCENSED CONTRACTORS DECLARATION FLOOR aiU -
I here6y affirm that I om licensed under pravisions of Chapter 9 SUSPENDEo ��NIT_
-(commencing witb Section 7000)of Division 3 of fhe Bosiness HEATER: ,�,Au
and Professions Code,and my licen:e is in full force ond effect. �'
307040 25 Air Inlets & Outlets ,S a
license Number Lic.Class �-20 - , V
Contracfor Air �ctamc� Tn�_ Date �� _ �
� � ��i .,..,, O
1 am e:empt under Sec. W
Plan check fee k.r < < < �= �
8.8P.C.for�his reason " �
PERMIT ISSU4NG FEE S f(1 O � � p`�.t-"
Dafe:
Si noture TOTAL FEE _ _
9 � a . . . -. ., .-
OWNER-BUILDER�ECLARATION PLAN CJiECK APPLICANT
I hereby affirm tbat I am exempi from ihe CoNractor's License � j �,j �-�_�_
Law for the following reason (Section 7031.5, Business and NAME
P^rofessions Code):
� I, as owner of the property, or my employees with AOORE55
wages as their so�e compensation,will do Ihe work and
Ihe strudure is not intended or offered for sale(Section CITY tE�.NO.
7044,Busioess and Professions Code).
owrvEa Cabot, Cabot & Forbes
❑ I,as owner of the property,am exclusively coniracling
with licensed coniractors to construct ihe projecf(Sec- �"u`��
Iion 7044,B�siness and Professions Code). ADDRE55 911 Nilshire Blvd. 1010
CONSTRUCTION LENDING AGENCV CiTY Los Angeles 9OOI7 7Et.NO.
I hereby offirm that ihere is a const�uction lending agency for ,
the performance of ihe work for which lhis permit is issued CONTRnCtOR Ajp Systems, II1C.
(Sec.3097,Civ.C.).
ADDRES$ 1454 S. Manhattan � -
Lender's Name
Lende�'snddress ��TY Fullerton CA TELNO_714 _4
STATE LIC.
i certify that I have read ihis applimtion and stme ihal ihe LICENSE NO. 30�040 CV+SS C-ZO
obove information is torrect.I agree to comply with all Counry
ordinances and Stole laws relating to building canstruction, .
and hereby authorize represenratives of this County ta enter � '
upo th' ie- tioned proper�y for inspection purposes. SEE REVERSE POR EXPIANATORY LANGUAGE
i� /` FY
S�gnature of Applimn�or Agent Do�e
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