HomeMy WebLinkAbout1180 DIAMOND BAR BLVD (20) WO.RK,RS'COMPENSATIONDECLARATION � APP"CATION FVR PERMIT �
�I hereby.df('nm�tha;I have a certiiitala of consent to self '
insure^o�o,re,!tficote of iNo�kers'Compensmion Insarance, �aA3eac HEATING - VENTILATING - AIR CONDITIONING
or a tenified copy thereof(Sec.3800,Lob.C.)
PollCy No. � p Y CE=B19(REV.10/81) - � �
olig-oo-0.l�, � �)t�s�n.� ,
� Certified copy is hereby fumished. �OUNTY OF LOS ANGELES BUILDING AND SAFETY
Cerrified copy is filed with the county b�ilding Inspec- FOR APPLICANT TO FILL IN BUILDING �
fiOn depdrtamen�. (PRINT pR TYPE ONLY) ADDRE55 Q
Dale�►—�✓-✓T Applican LOCAtITY �
NO. TYPE OF APPLIANCE OR EQUIPMENT � �FEE�
� CERTIFICATE OF EXEMPTION F M WORKERS' . NEAREST
COMPENSATION INSURANCE . CeOSS ST.
(Thfs s�cflon naad not be eompla}od IF fha work Involvod 6y ABSORPTION UNIT,BTV DISIRICT NO. PRp�E55ED BY
fhe permft is for one h�ndrad dollars(f100)or Isss.) - � ' Q
AIR HANDLING UNIT,CFM
I tertify that in the performance of the work for which this
, permit is issued,I shall not employ ony person in any monner
-so os to become subjett to the Workers'Compensation Laws. BOIIER,BTU qPPROVALS DATE INSCECTOR'S S�GNATURE
Dote ApplitaN - CO�'dPRES50R,BTU .�V oO ROUGH
NOTICE TO APPLICANT; If, af�er making this Certifita�e of yENTIIATION SVSTEM. FINAL
Exemp�ion, you should become subjett to the Workeri ,
Compensc!icn provisicnz of the Lebor Code,you musl forth- EVAPL`RATIVE COO!Eo VALIDATION
with comply with s�ch provislons or this permit shall ba
deemed revoked.- � � � puttNqCE: Fpu_GRqviTY
LICENSED CONTRACTORS DECIARATION FIOOR BTU �
I hereby aHirm that I am litensed under provistons of Chap�er 9 . SUSPENDEO UNiT_
'([ommencing wilh Section 7000)of Division 3 of the Business HEATER: WA��
and Professions Code,and my licenee Is In full force and effect. � . . �'
Ir /i � 4
License Number � ��7—�� Lic.Gess v� � , �
Confracfor � Dafe —� . � Q
� �3,�2qq F
I om ezempt vnder Sec. uVi
- Plan check fee #• • • • +8 y
B.BP.C.for ihis reason PERMIT ISSUING FEE$ �(�SQ I •o � �,$� ?
�Do/r�
s��„���„a - /Lu-x!� �C' t1�c'i� TOTAL FEE �,� Q � • . :8 7 0
OWNE - UILDER DECIARATION � M.4ru CHECK nrPliCnM • L ,er Q =
I hereby affirm that I om exempt(rom the Conhaciar� � • °'0 2 Q 5 0�
Law for the following reason(Sec�ion 7031.5,Bosiness ond Nnu�E � . � .
Professiom Code�: - � . - � �'O 5�a 7
❑ I, as owner of the propery, ar my employees w�th ADDRE55 �
� wages oz the�r sole tompensation,will do Ihe work ond �
the s�r�cfure is no�in�ended or oifered for sale(Section CITY TEL h� _ g
7044,Business ond Professions CodeJ. ,
OWNER
❑ I,as owner of the property,am exclusively tontrocting Y ,
with licensed contraUors ro construct the project(Sec- MA��
� �ion 7044,Business and Professions Code). aDDRE55 -
CONSTRUCTION IENDING AGENCY -� Citt TEL:NO.
I hereby affirm that rhere is a tonstruUion lending ogency for ,
ihe performonte af the work for whith this permil is issued CONtenCiOR l�� .
(Sec.3097.Civ.C.). � . . . ... . . _ . .
� � � ADDRESS a li " �� �. .
Lender's Name
- CIN �O�W �. TEL NO. . . . . .
lender's Address
I cerlif �hot I have read Ihis a licoi�on and srata�har ihe sinie / IIC.
y pp UCENSE NO. � �OS C1A55 - . . . . _ _ . .. . ...
obove information is correct.I agrea to comply with oll Co�nty
ordinances and State laws relatin9�o building construction, � . �
and here6y au�horize representa�ives of this Coumy to enter � � � � � � � -
u on the abo�e m o ed properry{or inspecuon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE _._
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