HomeMy WebLinkAbout1032A (5) WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PLRMIT �
I hereby affhm that I have o ceriificate of tonsen�to self .
insure'or a certificoie of Workers'Compensat�on Insurante, �bA3eac HEATING • VENTILATING - AIR CONDITIONING ZS
+ or a cerlified copy thereof(Sec.3800,Lob.C.) - CE-818(REV.10i81) ' - --��� �
voucy No. 1021516 �omPe�Y State Fund PH# 3 .
❑ Cerrified copy is hereby fuin�shed. � Bld ��' COUNTY OF LOS ANGELES �pB# 1208 BUILDING ANO SAFETY TR�r 42533
OX ,Ceriified copy is filed wiih�he munty building�nspeo-�- � FOR APPLICANT TO FILL IN ����� eUtlDiN� . '
lion deparfinenl. � (FRINT OR NPE ONLY) ADDRESS
Dare g-g-g7 APPIimn-.�� , �;�•� �ocnurr piamond Bar
NO. TYPE OF APPLIANCE OR EQUIPMEM � � FEE
CERTIFICAiE OF EXEMPTION F WORKERS' � � NEnREST
/ COMPENSATION INS ANCE� � � Ce055 ST.
.(Thf�secfion need not be tomplalod IF fha work Involvad by ABSORPTION UNIT,eTU DISTNICi NO. PRp�F55FD BY '
/ he permil is for one h�ndred dollars(5100)or less.)
P�p AIR HANDLING UNIT,CFM ,D �a� �
cerlify Ihat in the p=�formance of fhe work for which fhis � b{\
�permit is issued,I shall not empioy any person in eny manner BOILER,BTU -�
__. so as�o hecome sobject to+he Workers'Gompensarion Laws. nPraovais onre INSPECTOR'S SIGNATURE
�, �
Applicant COMPRESSOR,BTU 42.000 (�QQ ROUGH `�� ,/���
�� �ICE TO APPLICANT: IF, affer moking this Certifimte of VENTILATION SYSTEM ' . FINAL � �i c_.�—'"
'� Exemption, you should became sub�ect lo�the Wo�keri �
Compensolion provisions of the labor Code,you mvst forlh• EVAPORATIVE COOLER VALIDATION �
with comply with s�ch provisians or this permit shall be �
deemed revoked. � � - � - FURNACE FAV GRAVITY
IICENSEO CONTRACTORS DECLARATION FLOOR �Tu- � �
I hereby affirm Ihat I am licensed vnder pravisions of Chapter 9 SUSPENDFD � uNIT_ � �
� �(commencing with Section 7000'o(Division 3 of the 8usiness HEATER: WA��
and Professions Code,and my license is in foll fwce and effed. - - � � - �"
a
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License Number q�g�gg Lic.Class�„�g - V
co�r,oc+o. ZrivneWest oare 8-8-87 tlet ' �1 0'a 2 A p I
❑ �I am exempt onder Sec. ' � � . . _ .. � �� � � � �8 w
Plan check fee : �
B.BP.C.for this reason� � '2 3��Q �
Dare: PERMIT ISSUING FEE S 10 50 e�2 3 2,D Q c=i
Signmore TOTAL FEE • (� t
- OWNER-BUILDER DECLARATION ttAN CHECK APP�ICANT � O�2`�`8 7 .
I hereby affirm tho�I am eaempt irom fhe Convador's License � D .
� -a(or Ihe iollowing reoson(Setlion 7031.5,Business and NAME _
'---, �essionsCode): � .
�� I, as owner of the property, ar my employees with AooRE55 �
� woqes as iheir sole compensation,will do Ihe work ond�
ihe s�ruclure is not intended or offered for sole(Section ��TY TEL.NO.
704e,Business and Professions Code�. ' �'�' .
� OWNER presley Company �
❑ I,os owner of the property,om exdusively tontrac�ing . .
wilh licensed controcfors fo tonslrutt the project(Sec- Ma�� 17991 MitehEll SOuth ��
tion 7044,Business and Professions Code). ADoaE55
CONSTRUCTION IENDING AGENCY �- QTY irvine C8 92714 rei.N�4714)�-660-0660 � ,
I hereby oifirm thot there is a conshuction lending agency for , � '
1he performante of the work for which this pe�mit is iszued CONTRACTOR" - ' � -- .
IrvineS4est Ht & Air _ . _._ __..
(Sec.3097,C(v.C.). �
� ADDRESS ��� (3S Southern Ave. � - �- ' �- - ��- � � �
lender's Name � �
Lender's Address
��TY Orange Ca 92665 rEi.No(.714) 921-080 . -
I certify ihot I have read this application and state iho�the iicenise No. 468609 .-.cuss- �—ZO .
above informotion is carrect.I ogree to comply with oll COunfy
_ _
ordinances and Siate laws relating to boilding conslrudion; �
and hereby au�harize representa�ives of�his County to enter � _ - ���-- �- � � �� -
upo he obove-menti�ed�proper�y for inspection purposes. � SEE REVERSE FOR EXPLANATORY LANGUAGE . . . . . . . . . .
/C� 8-8-87
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