HomeMy WebLinkAbout1031A (5) � WORKERS'COMPENSATIONDECLARATION qPPLICATION �OR PERMIT �
�� I��r�by affrm Ihol I have o certifimfe of tonsent to self
� insure,or a cerrificaie of Workeri comPe�Saro�i�5��a��e, . HEATING-- VENTILATING - AIR CONDITIONING
or a cedified copy Ihereof(Sec.3800,lob.C.) 76A36CC "
CE-818(REV.10/81) � � - -
�cy No. 1021516 compa�y State Fund � PH� 3
Certified copy is hereby f�rnished. B u COUNTY OF LOS ANGELES J B 120 BUILDING AND SAFETY TR 42533
O .Cer�ifled copy is filed with the county building inspeo- FOR APPLICANT TO FILL IN euRDiNG
tlon deparlment. (PRINT OR TVPE ONLY) ADDRE55 '3�
Date g, g��� Applicom � �«A��TM iamond ar
NO. TYPE OF APPLIANCE OR EOUIPMENT� � . FFE
CERTIFICATE OF EXEMPTION FR 1 WORKERS' NEaeESi� �
COMPENSATION INSU ANCE CRO55 ST.
(Thls sedton naad not ba compleled if fhe work involved by ABSORPTION UNiT,BTU Di51RIC1 NO. PROQSSED BY �
the parmil Is for ona hundred dollars(5100)or le�f.) � � q�g HqNouNc IJN�i,CFM
. I ce�lify that fn Ihe perfo�mance of the work for which Ihis ��� 1 p . �QI6�Q
permit is issued,I shall not employ any person in any manner � gpILER,8Tt1 � --
— so os to became subject�o the Workers'Compensalion lows. AVPROVnts DATE �NSPEC70R'S S�GNATURE
COMPRESSOR,BTU49.l1n(1 � �� ROUGH ��4 �
•� �� applicanl �
ICE TO APPLICANT: If, after making this-Certifimte of VENiILATION5Y5TEM FINAI
Exemp�ion, yov should become subject to the�Workers'
Compensotion provisions of�he Lobor Code,you mus�forth- EvaFOea7NE COOIER VALIDATION .
with tomply with such provisions or this permit sholl be
deemed�evoked. � • FURNACE: FAU - GRAVITY �
LICENSED CONTRACTORS OECIARATION FiooR � � '
I here6y offirm�hot I om licensed under provisions of Chopter 9 HEAiER: SUSPENDED � UNiT_ �
'(commencing with Seclion 7000)of Division 3 oi the 8usiness - WA« �
and Professians Code,and my license is in full force and effect . � d
O
License Nvmber �9 Lic.Class��8 � - � �-- - � ► V
K
�onnocror IrvineWest Date 8—$—g7 - _�� ��� A . V
❑ I am exempt under Sec. . _ . . _ �s • • • •8 d
Plan check fee y
B.BP.C.for this reason PERMIT ISSUING FEE S 10 50 /� / � • � z��2 Jr z
Da1e:
Signarure TOTAL FEE / • • � 2�,2 5,T—�
� � OWNER-BUIIDER DECIARATION PLAN CHECK APRICANT ��2 Jr,�S 7
I hereby aiiirm that I am exempt f�om the Conlrattoi s License � .
-.v for the following reason(Section 7031.5,Business and NAME -
� -: �essionsCode�:� - , � � �
1, as owner of the properfy, or my employees with ADDRE55
- waaes as iheir sole compensalion,will do ihe work and
the structure is no�in�ended ar of(ered for sole(SeUion Ciiv - TEL.NO.
7044,8usiness and Professio�s CodeJ. � ��� � � .
OWNER presley Company � - �
❑ I,os owner of Ihe property,am excl�sively controcting
wi�h licensed tontracrors ro canstrucr the projed�Seo �'�'A�� � � - .
fion 7044,B�s��ess o�d Professions Code). ' ADDRE55 17997. M].tCIYCll $011t}3 .
CONSTRUCTION LENDING AGENCY - CiTY Irvine Cd 92714 ��.M�714)�660-0660 .
1 hereby aflirm�hat there is a construction lending ogenty for � ► �
1he perfo�mance of the work for which this permil is issued CONTRACTOR - �� �- � .
(Sec.3097,Civ.C.). � . t Air . . . ._ ....
- - - � AD�RESS � (j3H Sauthern Ave. - - - �� - - � � ' � � � �
Lender's Name
aTr. prange Ca 92665 TEi.No(714) 921-080 �
Lender's Address
I certify thot I have read this application and state thar rhe � �j�ENSE NO. 468609 CLA55-C-2� ., .. , _ ,
d6ave informa�ion is correct.I aqree ro comply with all Counly
ordinances and State laws relming to boilding construUion, � _ � _
and hereby outho�iza representa�ives of ihis County to enter � .
u e above-me r�o c*d property for insped�on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
� 8-8-87
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