HomeMy WebLinkAbout1370 VALLEY VISTA (59) WORKERS'COMPENSATION DECLARATION � APPLICATION �OR PERMIT �
t hereby affirm that I have a certificate of tonsent to seif � �
insure,or a certificate ot Workers'Compensation Insuronce, ���� HEAi1NG - VENTILATING - AIR CONDITIONING
or a cerrified copy rhereof fSec.3800,lab.C.) CE-818 kEV.10/81
WC2-162-030337-087 � �
P❑ol�ity No. Company I-ihart,y Mutual
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed with�he c t bu' ing'nspec- FOR APPIICANT TO FILL IN Bl1tLDING
tiondepartment. �paiN70ttrvveON�v� ADDRE55 First Floor Corridor/1370 Yalle Vist
Daie 1�1�89 Applicant LOG^��T� Diamond Bar
NO. - NPE OF APPLIANCE OR EOU�PMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEnRE57
COMPENSATION INSURANCE CRO55 Si.
(This sactlon ncad�ot kw complafad if tha work inrdved by ABSORPTION 11NlT,BTU �ISiRiCT NO. PROCESSED BY
the parmli 4 4or ona haadr�d dollars(5100)e�I�u J /�
I Certi{y ihpt in fhe performance of fhe work for which ihis AIR HANDLING UNIT,CFM �
permit is issued,I shal�not employ any parson in any manner
so as to become subjed to the Worke�s'Compensalion Laws. BOILER,BTU avpRovnts oare I SiECTOR'S SIGNAiUkE
DC��B opplicant COMPRESSOR,BTU ROUGH
'�TICE TO APPIICANT: If, after moking Ihis Certifica�e of VENTIIATION5Y5TEM FINAI ��-ti �
nplion, you should become subjecf to ihe Wo�kers'
.,mpensation provisions of the tobor Coda,yoo mUst forth- EVAPORATIVE COOLER - VALIDATION
with comply with svch provisions or ihis permil shall 6e
deemed revoked. FURNACE: FAU_GRAVIN �
LICENSED CONTRACTORS DECtARATION PtOOR BTu
I hereby affirm thal I am licensed under provisions of Chapter 9 SUSPENDED UNl7_
�(commancing wi�h Section 70W)of Division 3 of fhe Business HEATER: yyqLL
aod Professions Code,and my licerne is in full force and effecC �
307040 � Inlets & Outlets sZ
Lice�se Nvmber Lic.Class �'2Q (�j
7 Fire Dampers � Ub � �e
Con��acro�Air Systems, Inc. po�e - �1 � 'N �
❑ 3! 9a ` v
I am exempt�nder Sec. �y
Plcn check fee r ,• . � : f N
B.BP.C.for this reason PERMIT IS$UING FEE� � (� z
t y�`.� - _
Date: _
Signature TOTA!FEF Q ,j � e , _
� . 'i� _
OWNER-BUILDER DECLARATIDN PLAN CHECK APPLICANT
1 hereby affirm ihat I am exempt from the Conlractor's Lirense � � �,� [,—�i,
Law for the following reason(Section 7031.5, Business and NAME
Professions Code�:
� � I, as owner of fhe properly, or my employees with �DRESS
� wage5 as their sole compensation,will do ihe work ond
the structure is not intended or offered for sole(Sectian CITY TEL.NO.
7044,Business and Professions Code).
OWNER Cabot, Ca ot & Forhes
� ❑ I,as owner of ihe property,am excl�sively contracting
with licensed canrroctors to constroct fhe projed(Sec- '�'��
tion 7044,Business and Professions Code). +4DDRE55 911 Wilshire Bld. 1010
LONSTRIJ[TION LENDWG AGENCY
I hereby affirm ihm there is a wnstruction lending agency for C�tY �OS An eles �A 90017 ���NO.
the performance of rhe work for whlch this permH Is Issued COtviRnCiOR A71' Systems, I�C. �
(Sec.3097,Civ.C.).
ADDRESS 1454 S. Marthattan
lender'e Name
aTr Fu112rton, CA rei.No. 714/992-40.90
Lender's Address
STATE LIC.
I ce�rify�hot f have read this application and state tha��he LICENSE NO. 3OIO4D CLA55 �-20
above information is corred.1 agree to comply with all County
ordino�ces and Siate lows relaling to 6uilding construclion,
o�d hereby outhorize representatives of ihis County io enter
upo t e ib e-m tioned property for inspection purposet. SEE REVERSE FOR EXPLANATORY LANGUAGE
11/16/88
Siqnalure of Applimnt or Agem Date .
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