HomeMy WebLinkAbout1029A (5) WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PERMIT �
I hereby affirm thof I have a ce�tificate of consent lo self '
insur�,'or a tenifim�e o(Workeri Compensation Insoronte, 76A3�� - HEATING - VENTILATING - AIR CONDIT{ONING
.or a ceriilied copy lhereof($ec.3800,Lob.C.) � GE-BiB(REV.10/81) � � - "� � � � - - �
P❑olity No.��oCompany S���e .�....�_ ����'y OF LO$ANGELES BUILDING AND SAFETY
Certified copy Is hereby furnished. JOB�r 1208 TR# 42533
� Cerrified copy is�iled wuh rhe mun�y building inspeo FOR APPLICANT TO FILL IN BUILDING
Ilondepariment. � (PRINTOR7VPEONLY) ADDRE55 I�;ZE. Estoril DL.
pa�e B—H—B�APPlicant ��^��Tv
NO. TYCE Of APPLIANCE OR EOUIPMENT FEE Diamond Bar
CERTIFICATE OF EXEMPTION F WORKERS' NEAREST
COMPENSATION INS ANCE Grt055 ST.
(This sst}lon noad noT bs complefed if Ihe work Involvad by .- ABSORPTION UNIT,BTU Di51RiCI NO. VROCESSEO BY
Ihe permlf Is(or one hundred dollors(SI00)or lec�.) pIR HAN�LING UNIT,CFM ]�
I certify Ihol in Ihe performonce of ihe wo�k for which Ihis � �,U ���h e
permit is issued,I shall not employ ony persan in any manner . � _
so as to become subjecf to the Workeri Compensaiion Laws. BOitER,BTU APPROVAI$ UATE INS�ECTOR'$$IGNATURE
epP�.�a�� COMPRESSOR,BTU �O [�� ROUGH `� �
�ICE TO�APPLICANT: li, after mokin9 this Certifitate of �/ENTILATION SYSTEM FINAL _/�
Exemption, you should become s�bjec� fo tha Workers' '
Compenso�ion provisions oi Ihe Lobor Code,you musl forlh• [VAPORATIVE COOLER � � VALIDATION
with comply-wifh su[h provisions or this prrmi�choll be '
deemed revoked. . - � FURNACF. FAU_G¢AVIIY�_ '- _ �
tICENSED CONTRACTORS DECLARATION . FtOOR. BTU bY5 IJIJ � .
I here6y aifirm thot 1 om licensed under provisions of Chopter 9 SUSPEN�ED -� UNiT_
�(commencing with Section 7000)of Division 3 of the Business HEATER: wA��
ond Professions Code,and my license is in(ull Porce and effeU. �- � �'
468609 c-20 1 1 '� 0
License Number tia Class � � � � � , � � V �
�
Convactar�rvineWest Dofe B-H-H7 - O
� ❑ I am exempt under Sec. _.. . '�� O L 9 A v
Plan check fee a
- B.BP.C.for this reason�
- PERMIT ISSUING FEE S 10 50 #' ' ' ' '8 ?
oa�e: .
Sgna�ure TOTAL FEE I •�3 2��
OWNER-BUIIDER DECLARATION PLAN CHECK APP�IC4NT . . • •Z J'G O O c=a
I hereby affirm tha�I om exempt from ihe Comwcror's License
�-�..for the following reason(Section 7031.5,Business and NAME � ��i 2 "Jr-'8]
��- � �SSIDIIS COdP.1: �
`-� I, os owner of fhe properly,or my employees wifh ADDRE55 -
woges as iheir sole compensa�ion,will do the work and . .
�the struUure is not intended o�of(ered for sale(Settion Qtt � 7EL NO.
� 704E,Business ond Professions Code). �
owNER presle Com an
❑ I,as owner of�he property,om e.clusively cantracting
with licensed mNracfors m conslroct 1he project(Seo- MA�t � ' -
lion 70d4,B�siness ond Professions Code). ADDRESS 1�g91 M1.tCI]ell. SOUt}1
� CONSTRUCTION LEN�ING AGENCY �� Citt Irv1IIe Ca� 92714 � re�.N6.714) 660-0660 . . � --
� �hereby afFirm�hot there is a conslruc�ion lending ogenty far , - �
fhe performance a(Ihe work for which this permil is iesued CONTRnROR IrvineWest Htg & Alr �� �
(Sec.3097,Civ.C.). - .._ _ . .. .
ADDRESS F>3H Southern.Ave. ._ , . . . . � • �. �. '
Lender's Name .
arr Orange Ca_92665 rei.nm.(714) 921-080 ____ ,
Lender's Address . � - �
STATE UC.
I ce.r�ty rha�i hv�e read this applicotion and sia�e�hat�he uceNse No. 468609 anss .e-20 _. _ _, _ _
above inFormo�ion is correcf.I agree 10 comply with ali Counly .
ordinances and S�o�e laws reloting to building constrodioq . . - -
and hereby outhorize represen�atives af Ihis County to eMer - �� � --�-�" � � -
upon the abnove-menii ned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
_ O�C.11L. 8-8-87 - . � .. . . � .. � .. . . . �. .
S�g aNre of Applicnnt or Agen� Daie . .. - - ' . .. ..-. - .. . .
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