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HomeMy WebLinkAbout1034A (5) WORKERS'COMPENSATIONDECLARATION -APPLICATION FOR PERMIT 1 hereby affkm thol I hove a cerliiicate of consent to self insu;b"or a certiiicate of worke�s'Compensation�nsurance, � HEATING - VENTILATING - AIR CONDITIONING , or o certified copy Ihereof(Set.3800,Lob.C.) 76A96aC . . � , CE-B16(REV.10i8i J' � Polity No. 1021516 �amPa�Y St8t2 FUrid PH� 3 � Certii�ed topy is hereby furnished. IIld n�'�A' C�UNTY OF LOS ANGELES JOB� 1208 BUILDING AND SAFETY TR�. 42533 � Ce'riified copy is filed wirh the couMy bvilding inspeo- FOR APPLICANT TO FILL IN euitomlG fiondeparimenl. (PRINTORTYPEONLY) ADDRESS ✓� Date g-8-87 ApplicoM tOUuiv ' DidIROl7d BdT NO. TYPE OF APCItANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION M WORKERS' NEaREST COMPENSATION INSURANCE CROSS ST. � (This saetion nood not be completod if fhe work Involved 6y �A650RPTION UNiT,BTu D151RiCI NO. FROCFSSEO BY Ihe parm�t is lor one hondred dollars(5100)or leu.) - . I cerlify ihat in Ihe periormonce of Ihe work for which�ihis A�R HANDLING UNIT,CFM 1� ���O�� i� permil is issued,I shall nat employ any person in any manner BORER,BTU � ��so as ro 6ecome subject�o Ihe Workers'Compensation Laws. � nearrovais DATF INSPECTOR'$SIGNAfURE ' "" Applicanf COMPRESSOR,BTU 42,000 ROUGH :�l� l� � �/� �ICE TD APPLICANT: If, ofter moking this Certifi[ate�of � VENTILATIONSYSTEM FINAL � _ L' Zr�' Exemption, yo� sho�ld become s�bjecl lo the Workers' � Compensation provisior5s of Ihe Lobor Code,you mus�forth• EVAPORATIVE COOIER � VALIDATION with comply wilh such provisions�or this permit shall be . deemed revoked. � � FURNACE: FAU�—GRAVITY - � � IICENSED CONTRACTORS DECLARATION 3 FLOOR 8TU CT� I hereby a(firm that I am litensed under provisions of Chopter 9 HEaTER: SUSPEN�ED UNii_ � '(commencing wi�h Seciion 7000)of Division 3 of�he Business ' wA�� . y ond Professions Code,and my license is in f�ll force and effect. � 0. �io�4a � License Number dFiRFi09 Lic.Class �`-��1 - �" ,� . V IrvineWest g-g-g7 � Inlets & Outlets , �. . ,�. ,g � ConhoUor Daie . �. ❑ I om evempt under Sec. .. . . � I ° 1 2�,L`5 a � Plan check fee � � �, 2 5= Z B.SP.C.for�his reason' � ' c� PERMIT ISSUING FEE S 10 50 ��1e� TOTAL FEE - 0 8 2 5-8 7 Signature� _ � � OWNER-BUIIDER DECIARATION � PL/+N CHECK naaliCANi _ I hereby aifirm�hot I am ezempt from the Contractor's license � I�w(or the following reoson(Sec�ion 7031.5,Business and NAME . ' � —��essions Code): - , _ � I, os owner Of Ihe property, ar my employees wilh ADDRE55 � wages as their sale compensolion,will do the work and ' the structure is nol iMended ar offered for sale(Section CiTv TEL.NO. 7044,Business a�d Pro(essions CodeJ. OWNER Presley Company ❑ I,os owner of the property,om extlusively coniraciing wiih licensed mnfrocrors to construct�he projed(Sec- DDRFSS 17991 Mitchell SOl3t1]� .. . lion 7044,Business ond Professions Code). � CONSTRUCTIONLENDINGAGENCY �- �- C�iv Irvine-Ca 92714 -��.N6714) �66D-0660 . I hereby offirm that there is a construclion lending agency for , the performance af the work for which�his permit is issued - CONTRACfOR IrvineWest Ht & Ai= � ���� (Sec.3D97,Civ.C.). . - , � - -- -� .. . - . . ' ADDRE55 � 63H Sauthern Ave: � � � � - � � � � ' � ��� ' ' Lender's Name urv Orange Ca 92665 re�.No(714) 921-080 -- - - - . Lender's Address STATE . _ I certify�hat I have reod this applicaiion and s�ate ihot the u�NSE No.. .468609 : nau_ c 20 ._ _ _ _ ._ . above informalion is coried.I ogree ta comply with all Covnty . ordinonces and Stote lews relating lo building ton5fruction, - _ _ . __ _ and hereby outhorize representatives of�his Covnty to eMer - � � � � � upon the abo e-meni'o cfd propery for inspedion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �:� 8-8-87 Si ,a�re of APPlimm or Agen� � Dafe ... .. .. . . .. . ..- .. . .. . . . . . _ . �, . , � . ' ,. � � � � ' �� '; . , \ ' � , �', , � . - . � • �,, ..._ �, • .. " ' . � '�' . . `, -, � `.,; �`, ` , , � , . . - ` . 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