HomeMy WebLinkAbout1370 VALLEY VISTA (62) ' ' WORKERS'COMPENSATION DECtARATION qpp��CAT10N FOR PERMIT � I
I•hereby af4irm that I hove o certificate of consen�to self
+nsure,w a carrificata of Workers'Compensotion Ins�rance, ��� HEATING - VENTILATING - AIR CONDITIONING
or a certified copy lhereof(Sec.3800,Lab.C.)
�C2-162-030337-087 CE-818(REV.10/81)
�cy o. Company Liberty MUtUdI
Certified copy is hereby 4urnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
�X Certified copy is filed with the co� ly bu' ing inspec- FOR APPLICANT TO FILL IN BIJILDING 1370 Valley Yista/ist. FL. (EaSt)
fio epartmenf. (PRINT OR 7YPE ONIV) ADDRE55 DUCt extension
Da�e� � 8 APP���a�� NO. TYPE OF APPLIANCE OR EQUIPMENT fEE ��L�TY Diartwnd Bar
CERTIFICATE OF EXEMPTI N FROM WORKERS' HEARESi
COMPENSATION INSURANCE CROSS S7.
(Thi�seciion need noi be compl�fed if tha work inrolrwl by A850RPTION UNIT,BTU OISTRICT NO. iROCE55ED BY
fha parmif Is for ono hundrod dol{ars(5�00)or less.) �
AIR HANDLING UNIT,CFM
I certify thot in the performance of the work for which this �
permit is is:ued,1 shall not employ any person in any manner .
so as to 6ecome s�bject to the Workers'Compensation Lows. BOIIER,BTU APPROYAlS DATE INSPEROR'S SIGNATURE
pa1e aPP�i�a�t COMPR€SSOR,BTl) ROUGH
NOT�CE TO AVPLICANT: If, ofrer making �his�Certificate of VENT�IATION$YSTEM FINAL (,�
� nptian, you should become subject to the Workers'
.�pensation provisions of the tcbar Code,you musf forth- EVAPORATIVE COOtER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE� FAU_GRAVITY
IICENSED CONTRACTORS DECLARATION Fiook siu
I hereby affirm thot I am licensed under pravisions of Chapter 9 SUSPENDED UNIT_
HFP,iER: WA��
'(commancing with Section 7000)of Division 3 of the Business
and Profeuions Code,ond my license is in full force and effect. �'
�uct Extension v � ��j � j f °'
license Number... 3�704(1 Lic Class r.�n y
► �' • s . c- o�' p�
Controcror Air Syc mc� Inr. pate 0
� 3 � ga2�: �:. u
1 am exempt under Sec. y�
Picn check fee � a
8.8P.G.for this reason . s � _.. ` - .. y
PERMI7 ISSUING FEE S l� $� g
oo�e� I 1 1 f:—;;'
Signature
TOTAL FEE �ZO,�
OWNER-BUILDER�ECIARATION tt/+N CHECK APPLICANT
I hereby offirm thai I am exempt from the CoNrador's License �
Law for Ihe following reason(Section 7031.5, Business and NAME �
Professions Code):
n 1, as owner of ihe property, or my employees wiih ADDRE55
� wages as iheir sole compensation,wilf do the work ond
the structure is nof infended o�offered for sale(Section ary rEl.NO.
704-0,Business and Professions Code). '
❑ OWNER Cabot, Cabot & Forbes
I,as owner of Ihe property,om exdusively con�rocting
with licensed cantroctors to construct the project(Sec- �"�A�� 911 Wil5hir2 Blvd. 1010
lion 7044,Business and Professions Code). ADDRE55
CONSTRUCTfON LENDING AGENCY ��TY �OS Angetes, CA 9OOLI TEt.NO.
I hereby affirm thnt there is a construction lending agency for ,
the performance of the work for which this permit is issued CONTRACTOR A•
(Sec.3097.Civ.C.). . �
ADDRESS 1454 S. Manhattan
Lender's Name
citv FulleYtOn, CA 7Ei.No. 714/992-4490
Lender's Address •
STATE LIC.
I certify thaf I hove read this applicalion ond store that fhe LICENSE NO.�O�G L,U LE,q� C—Zo
above informatian is correct.I agree to comply with all Cou�y .
ordinonces and State laws reloting to b�ilding construclion, .
and hereby a�ihorixe represantatives of�his County to enfer �
upo ove- entioned proper�y for inspection purposes. SEE REYERSE FOR EXPLANATORY LANGUAGE / �
11/16/88 /
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