HomeMy WebLinkAbout1035A (5) WORKERS'COMPENSATION DECLARATION � �
I hereby affkm thaf I ho�e a cer�ificaie of consent to self � APPLICATION FOR PERMIT
ins�.ve'or a certiiicale bf Workers'Compensation i�s��a��e, � . HEATING - VENTILATING - AIR CONDITIONING
� ci 6 cerlified mpy thereof(Sec.3800,Lab.C.) . 76A36aC . � � .
[E-BIB(REV.�IO/81) ' � -- � �
Policy No. �102151�mpany State FUIId PH#3 �
� �CerHfled topy is hereby�urnished. �� Bldg# COUNTY OF LOS ANGELES:� JO$# 1208 BUILDING AND SAFETY
�X Certified copy is(iled wi�h the counly building inspec- � � FOR APPLICANT TO FILL IN � � BU�LD�NG
fiondeparfinent. � ADDRES$ q E. Estoril �r.
(PRIM OR TVPE ONIY� �
Date �—g-87 Applitanf �� LOCALITY ^
N0. TY7E OF A7PLIANCE OR EQUIPMENT FEE �am
CERTIFICATE OF EXEMPTION FR WORKERS' NEAREST . .
� COMPENSATION INSURANCE � CROSS Si.
(This�acfton nood no}be camplatad i(fha work fnvolvod 6y ABSORPTION UNIT,BTU OIS1RICE NO. PItp�ESSED BY
the parmf}is{or one hundred dollars(5700)or lest.) .
I cerliFy Ihol in the performance af tFie work for which this AIR HANDLING UNIT,CFM (/\J
permit is issued,I shall not employ any pe�son in any manner �"" �a'1a�e
— so as to be[ome SvbjeU to the Workers'Compensation Laws. BOILER,BTU APvaOVntS DAiF MSMC70R'S9GNATURE �
AppiiCan� COMPRESSOR,BTU 42.000 J ROUGH �
��' .�ICE TO APPIICANi: If, after makin9 this Ceriificate of VENTitP,TiON SYSTE7u� FINAL ��
Ezempfion, you should 6ecome subject to ihe Wo�kers'
Compensotion provisions of fhe lo6or Code,you musf forlh• EVAPORATIVE COOLER � ALIDATION
with comply with su[h provisions or this permit shall be
deemed revoked. � FURNACE: FAU�_GRAVITY �
LKENSED CONTRACTORS DECLARATION � F�OOR eiU
I hereby affirm thal l am licensed under provislons of Chapter 9 HEA7ER: SUSPEN�ED UNIT_ �
�(commencing with Sec�ion 70W)of Division 3 of the 8usiness � wa.tt _
, and P1ofessions Code,and my license is in fu�l force and effect. � '-� � �'
Inlet L� a
O
License Number�}�g�a9 Lic.Class�_ �- � � � � � , V
IrvineWest oo�e A-s-B� j� b�5 A �
Contmctor . . . . . .
❑ I am exempt under Sea , . � n• • • ' •8 w
Plan check fee a
� B.BP.C.fo�this reason� � a � C�Q,p Q Z
PERMI7 ISSUING FEE 5 10 0
signoture �
���e� TOTAL FEE • " 1 q r�0�
OWNER-BUILDER DECLARATION MAN CHECK APPLiCANT O B.2 5`8 7
I hereby aiFirm Ihol I am ezempt irom fhe Confroc�or'S License � . .. � �
lnw for Ihe following reason�Sedion 7031.5, Business and NAME � .
�.. �ssions Code): ' - � � � , � � .
����LJ I, os owner Of fhe properly, or my employees with ADDRE55
woges as thetr sole tomoensation,will do the work ond
the strucrvre is not intended or ofiered for sale(Section GTY - TEL NO.
7044,Business ond Proiessions Code). � � �
. OWNER Presley Company
❑ I,as owner of the properly,am e�clusively conlracting �
with licensed contrado�s ro construct the project(Seo- � ��� � � � - , �
tion 7044,Business and Pro(essions Code): AD�RESS 17991 M].tCh@ll SOUth
CONSTRUCTION LENDING AGENCY CIN Irvine Cd 92714 TEt.N�.�14) 660-066
I hereby affirm Ihallhere is a construcfion lending ogency(or
Ihe performance of the work for which Ihis pe�mit is i55oed CONTRACTOR - � � "" - ' - ► �
(Sea 3097.Civ.C.). .. . . .- .
A�DRE55 � -- 63S Southern�Ave. -- -- � - " - � - �
Lender's Name . �
aTv Orange Ca 92665 - TEi.No.(714) 921-080
tender's Address
I certify lhat I have read�hls applimtion ond stote thal ihe UCENSENO. � 4�8609 CLn55 -C-20 _ .. . .._ . � , _
obove information is correcf.I agree to comply with oll County '
ordinances nnd Slate laws relating to building construdion, _ . '
and hereby authorize representolives oF this CouMy�o enier � �� � � � � � -�- � -
upon the above•menri ne property for inspetlion purposes. SEE REVFRSE FOR EXPLANATORY LANGUAGE
8-8-87
Slgn e of Appiicom or Agenf Da�e
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