HomeMy WebLinkAbout1033A (5) WORKERS-eonnPeNsnTioNoeaneArioN � APPLICATION FOR PERMIT �
I hereby affirm�hat I have a tertifica�e of consent to self
insure;or o cerrfica�e of Workers'Compensation Insurance,' �6A3tec • NEATING - VENTILATING - AIR CONDITIONING
. or a cerlified copy thereoF(Sec.3800,tab.C.)
1021516 State Fund CE-818(REV.ID�81� PH� 3 �
Policy No. Company
� Certified copy is hereby fornished. � -B1dcJ# � �
COUNTY OF LOS ANGELES JOB# 1208 BUILDING AND SAFETY TR# 42533
� Certified copy is filed with rhe county buildinq inspec- FOR APPLICANT TO FILL IN � Bui��inlG E. EstOril Dr.
fion deparimenf. . � (PRINT OR NPE ONIY) ADDRES
Oa�e�—$—$] Applicam� IOCAIITY � D1dif10TIC; B8Y'
. NO. TYPE OF APPLIANCE OR EQUIPMENT � FEE
, CERTIFICATE OF EXEMPTION F M WORKERS' NEaaeSi _
COMPENSAiION INSURANCE - GRO555T.
i (Thlt set}lon need nof ba eemplefed if fhe work inrolvad 6y . ABSORPTION UNR,BTII D6raicr No. rxoCESSED er
}ha p�rmit is fo�ona Aundrod dollars(SI00)or lese.) AiR HAN�LING UNIT,CFM- � -
' I cer�ify Ihat in the periormance of Ihe work for which thiz �� �QIQ��
��_�` permit is issoed,I sholl not employ ony person in any manner g04ER,BTU � --
so os�o become subjecr ro rhe Workeri Compensation laws. aovaovais DA1E INSPEtlOR'S S�GNATURE
1� opplicanl � �rJ COMPRESSOR,BTU42�000 � � ROUGH �l�fj
�ICE TO APPLICANT: If, after mOking thi5 Certifica�e OF VFNTILATION SYSTEM � FINAL _ .�-� C������"
Exemption, you should become subjeU �o ihe Workers'
Compensation provisions of'ihe Labor Code,you musl forlh- EVAPORATIVE COOIER - VAUDATION
wiih comply with svch provisions or this permit sholl 6e
deemed revoked. � - FURNACE: FAU�_GRAVITY
IICENSED CONTRACTORS DECLARATION � FLOOR eT -
I here6y afiirm Iha1 I om licensed under p�ovisions of Chapier 9 SUSPENDED UNIT_ �
HEATER: . wA��
'(tommencing with SeUion 7000)o{Division 3 of the Business }
and Professions Code,and my Ilcense is in full force and efied.� � � y
�License Number 468609 Lic.Class r-20 � -- - � � � � �� •�1 0 a 3 A OV
Inlets & Outlets c
Conirocror IrvineWest Date' 8-8—a7 . - . . __ #.' • • •'� •Fj �0
r
❑ �I am exempt under Sec. . . . _ . . 1 • 1 2�,2$ � eVu
Plon check fee a-
8.8P.C.for ihis reason' ],0 50 � • � 1 2 1.2 5 U Z
PERMIT ISSUING PEE S
� �afe: . �a 2 rJ�8 7
Signature
TOTAL FEE /,7
OWNER-BUILDER DECLARATION - P�aN CNECK nPauCANT
I hereby affirm ihat I om ezempf from Ihe Controcfor's License ' , . D � �
��^w for ihe following reoson(Sec�ion 7031.5, Business and NaME . .
• ; �essions Code): � . �
}�� I, os owner of the property, or my employees wirh aDDRESS
woqes as�heir sole compensaiion,will do ihe work ond
the shucture is not inlended or offered for sale(Section CiTY TEL.NO.
7044,6usiness and Pro(essions Code). .
OWNER Presley Company . -
❑ �I,as owner of the properiy,am exclusively conlrocting .
with licensed commUors to mnstruct 1he projecl(Sec- - MA�� � 17991 MitChBll Sout -- - .
� lion 7044,Business ond Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY � �iTy Irvine Ca 9271 . �� N , —
I here6y affirm Ihallhere i�a conslruclion lending agency for . ' �
the performance oi Ihe work for which ihis permit is issued - �ONTRACTOR irvinewest-Htg & A1I' - � - -
(Sea 3097,Civ.C.). . . .. .. .. .- , . . .
aooaess 636 Southern Ave. _ _ _ _ _ ..
lendei s Name �
crtv Orange Ca 92665 rei.No.��14) 921-08
Lender's Address � � - �
I certiF that I have�ead Ihis a lication and stote that Ihe S7ATE 468609 UC. C—
Y PP IICENSE NO. . .. - ClASS .. . _.. .. __ .... . _. .... _
above information is co�recl.I agree�o comply with all Co�nty .
o�dinances ond State laws reloting to building mnstruction, .
and hereby authorize representalives of this Counfy to enter . - � � �-�- �� �� � �� � - �
upo the obove-men�� ed p�operiy for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE . � -
. ... . .... ... .
.�
8-8-87
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