HomeMy WebLinkAbout1180 SO DIAMOND BAR i �
�. WOPKERS'COMPENSATIONDECIARATION � APPLICATION FOR PERMIT
' I hereby affirm Ihat I have o tertificota of consenl to self -
insure,or a cerri(icare of Workers'Compensarion Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a carfified copy Ihereof(Sec.3800,lab.C.) 76n36aC .
t CE-818(REV.10/81)
Policy No.��CompanYs'�}�!- CUMpt�/�.it/�p.J � � � .
1� Certifed copy is hereby fumished. ' COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Cerlified copy is filed wilh Ihe counly 6uildi inspec- FOR APPLICAN7 TO FILL IN - BU�tD�rlG �+ � �
tion deporlmenL (PRIM OR TYPE ONLY) ADDRESS � � .�d��
Date1L'aSL�1..L_ApplicaN LOCALITY � a
NO. NPE OF AP7LIANCE OR EQUIPMEM . FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE � � - CeOSS Si.
(This sacffon naed no1 ba complelod if Ihe work involvod 6y a850RPTION UNIT�BTU DISiRiCi NO. PRp�ESSED BV'
fha p¢rmif ts for ona hundrad dollnrs(sI00)or le�s.) � � AIR HANDLING UNIT,CFM -
I certify�hat in the performance of�he work for whith this- �� ���
permit is issued,I shall not employ ony pe�son In ony manner
so as fo become subjeU to the Workers'COmpensotion LowS,� BOILER,BTU pooROVAlS D��E INSPECTOR'S SIGNATl1RE
Do�e App�icanf � COMPRESSOR,BTU ROUGN
NOTICE TO APPIICANT: If, afler making this CertiFico�e of I � VENTilATiON SYSTFNt �DO C'�ty� S � FiNAL
Exemption,-you should become subject to rhe Wo�kers' �
Compensation provisions of ihe Lobor Code,yoo must forrh- Eyqc�Rqin�Cpp�Eg. VALIDATION
wilh cemply wi!h such provisions or ihis permi� shail be
deemed revoked. � � � FURNACE: FAU_GRAVITY
� LICENSED CONTRAC70R5 DECLARATION FIOOR etu ' �
I hereby aflirm thot I om licensed under provisions of Chopter 9� � HEATER: SUSVENDED UNIT_ _
'(commencing with Section 7000)of Division 3 of tha B�siness 'n'A« � �
and Ro(essions Code,ond my Htense Is in full force and elfect. " �� " y
/'�.�� �z�. O c� o
License Number�47�y Lic.ClassS..�V.. . � � � V
�+ K
Contractor�SG7�P�+[_Ul�Date���n �7 �` � .
� I am exempf under Set. . .. . . __ _ ' v
Plan check fee W
a
�
8.8P.C.fo�Ihis reason� Z
� PERMIT ISSUING FEE S \O �
oora:
TOTAL FEE ('j 7
Signa�ure
OWNER-BUIIDER DECLARATION � PLAN CHECK APauCANT •
I hereby offirm ihat I am exemp�from the Conhactor's license � �J G G� A � ��
Low�or the foliowing reason(Seclion 7031.5,Buslness and NAME . �. • • � r 8
� �Professions Code): '
❑ �, as owner of the property, or my employees with ADDRE55 - � � ' •4 a 5 0
wages as�heir sole compensalion,will do the work and � CIN TEL.NO. � ����Q.J��z
the strutlure Is not In�ended or offered fo�sole(Seclion
7044,Bosiness ond Professions Code). , � � � �,L O�8 7 '
OWNER � P
❑ I,as ownei of the propery,am eacl�sively tontrot��ng MA" '
wilh licensed tontrocrors to consirud rhe project�Sec-� ADDRE55 Q S IQ/yl .�J /
tion 7044,Businese ond Professions Code). � '
CONSTRUCTION IENDiNG nGENCY aTr N� ! , h�.No. -- � -
� I hereby offirm ihat ihere is a construUion lending agenty(or - ,
the performance a(Ihe work foi which ihis permif is issued � �ONTRACTOR -��` � �
(Sec.3097,Civ.C.). . . . . - .. -.- .
. ADDRESSg .�{. � ...,. _ . . _ .� . . . . _
lender's Name /�j �} �
. CIN UP !L'.i7� _ . TEL.N0.7�'�TU��IlUS - . -- . . . . . . ..-.
Lender's Add�ess
I certif that I have read this o litation and sfate Ihat the STATE nl LIC.
y pp LICENSE NO. � Q} CLASS C��
obove informmian is correct.I ogree to comply wi�h all Counry .
ordindnce5 and Stale lows relaling lo bVilding construc�ion,
ond hereby authorize representalives of this County to enter . - � � . - -
a on the npov eniio�e roper�y for inspec�ion purposes. SEE REVERSE FOR EXPLANATORY IANGUAGE. __ _
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