HomeMy WebLinkAbout1030A (5) � WORKERs�oM�NSAT�oNOE«ARAT�oN � � AppLICATION FOR PERMIT
`r.t.';s�.`.lor arcert f ca��e of Worke s'1Compensot on Insuron�If �
r or a certified copy thereoi(Sec.3800,106.C.} �eA3e�c �- HEATING - VENTILATING - AIR CONDITIONING
CE-818�REV.10�81) -- --
POolicy No. 1021516 Company State Fund PH# 3
Certified copy is hereby furnished. � COUNTY OF�LOS ANGELES�-- BUILDING AND SAPETY
� Certified mpy is filed with the county bu�lding inspec- � . POR APPLICANT TO FILL IN � � BU�LD�NG
tian deparfinent. , � ADDRE55
(PRINT OR TYPE ONLY)
Dale 8 8-S� APPlicanf . � LOCALITY
NO. TYPE OF APPLIANCE OR EOUIPMENT FEE
CERTIFICATE OF EXEMPTION M WORKERS' NEAREST •
� COMPENSATION INSURANCE - CROSS ST.
(Thle tsttton nsad not ba complvfed li Iha work involvod by AeSOR7TION UNIT,BTU DiSiRi�i NO. PROCESSED 6Y
ihs permh is ior ona hundred dollars(5100)or lass,) AIR HANDIING UNIT,CFM 1�/� l �
I cerlify that in the performance of Ihe work for which this ' ,� I ' IQ\a� e
_ permit is iss�ed,I shall not employ ony person in any manner
so os lo become su6ject fo the Workers'Compensation Laws. _ BOILER,BTU aoaaovnts DATE INSPECTOR'S SWNATURE "
� COMPRESSOR,BTU � ROIJGN X' �'�� �
�.ti Applicont �
ICE TO APPLiCANT:�If, after making ihis Certificate o( • VENTILATION SYSTEM � FINAL
Exemption, you shouid 6ecome eubjecf �o the Workeri
Compensotion provisions oi the Labor Code,you must fo�th- evnvOtiqiroE COOLER ALIDATION
with tomply wi�h s�ch provisians or this permit sholl be
deemed revoked. FURNACE: FAU GRAVITY �
UCENSED CONTRACTORS DECLARATION FIOOR �TU
I hereby affirm tha�I am licensed under provisions of Chapter 9 SUSPENDED NiT_ �
HEATER: WAII
'(commencing with Secfion 7000)of Division 3 of the Bosiness }
and Professions Code,and my licensa is fn full force and effecl. y
�
License Number 466699 ���•Class e i� lets & Outlets y� ► �� ���A �� �
irvinewest 8-8-87 . #. ,� . �$ �
Con�roctor pote -� � � -
F—
❑ I om exempt under Sec. � � , � � 2� 2 5 V
Plan check tee � d
B:BP.C,for this reason PERMIT ISSUING FEE� 10 50 � ^ 1 2 1,2 5 c� �.�Z_
Do1e:
Signature TOTAL FEE / / , 0�2.5�'8%
� OWNER-BUILDER DECIARATION PLAN CHECK APPLIfANT , �
I hereby affirm that I am eKempl from ihe Conlrottor's License � �
yior the following reason(Sec�ion 7031.5, Business and NAME
�' '�. lessians Code): _
. u I, as owner of Ihe property, or my employees with ADDRESS
� . wages as their sole compenso�ion,will do the work ond .
Ihe slrutture is not intended or ofFered for sole(Seclion CITY TEL.NO.
7044,Business and Professions Code). �. OWNER Presley Company �
❑ I,os owner of the properly,om exclusively controcting
with licensed con�roctors to construct the projed(Sec- MAit 1 C e O¢ - -
tion 7D44,B�siness and Proiessions Code). ADDRE55
CONSTRUCTION LENDING AGENCY � CiTY � rV1Re d �i N -
1 hereby affirm that there is a construc�ion lending ogency for ,
Ihe performance of ihe work for which�his permit is issued COMRACTOR IZV1I12W25t HtCJ & Alr- - �- -�-
(Sec.3097,Civ.C.). - ' �
._ .. .. .. . . .
' ADDRE55 � 63B Southern Ave. .. . ...... .. � � � �� ' ` �'
Lender's Name
cin. Orange Ca 92665 re�.NoS 71 —
lender's Address -
STATE � LIC. C—
I certify that I have reod this application and stale Ihal tha tICENSE NO. - � � ClASS - - � �� � � �- - - -�� �� � � -� � . ..
a6ove informa�ion is correc�.I agree to comply with oll Counry
ordinances and State lawe reloting to building mnstruction, ' - �
_ . .. .. . . . . ..... . . .
and hereby authorize representatives of ihis Counly to enter - - -��� � �� � -- - _
upon he obove-mention d properly For,inspettion p�rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE .
�r`� 8-8-87 _ _
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