HomeMy WebLinkAbout1028A 1038A WORKERS'COMPENSATIONDECLARATION APPL'CATION FOR PERMIT �
I hereby affkm that I hove o cerrificote of consen�to setf - �
ins�rt�;or o certificore of Workers'Compensarion Insu�once, 76A3eac - HEATING - VENTILATING - AIR CONDITIONING
. or a cerrified coPY the�eof(Sec.3800,lob.C.� �-818(RfV.10/81)... -. . . . . . .
Policy fdo. 1l1��,7 Si cfompany $tdtQ Furi$ � pg g
❑ Cer�ilied copy is hereby furnished. BLDG� � Co�NTY OF LOS ANGELESJOB# 1208 BUILDING AND SAFETY TR� 42533
� Certified capy Is filed wifh Ihe county bufiding inspeo- . FOR/�PP��[/�rJT TQ FI���rJ -- BUIIDiNG. - �
tiondeportmenr. aooee55 � �} E. Estoril Dr.
(PRINT OR TYPE ONLV)
Date 8-6-87A lita � IOCAUTY �
PP NO. TYPE OF APPLIANCE OR EQUiPMENT � FEE n
CERTIFICATE OF EXEMPTION M WORKERS' . NEnkESi
COMPENSATION IN RANCE - . CRO55 Si.
(Tbb��c1(on nwd nof bs eompl�tad i(fh�work in4olv�d by !BSOR7TION UNIT,BTU DISiRiCI NO. GRp�f55ED BY
, }he parmi!ta for on�hundred dollan(SI00)or la�a.) ���
, I certiiy ihot in the periormance of the work For which this AIR HANDUNG UNIT,CFM �Q,O n e
permit ts issved,I shall not employ any person in any manner gOi�ER,BTU
so os to become subject�o the Workeri Compensotion laws. avvaovnis DAiE INSPECiOR'S SIGNAiURE
COMPRESSOR,BTU 4Z�OOO U � ROUGH
APPlitant -
� '� .�ICE TO APPLICANT: If, offer making fhis Ce�tifi[o�e of VENTIULTiONSYSTEM FINAL �—-
Exemption, you should become subjecl to the Workers' � •
Compensmion provisions of the Labor Code,you must forth- - EVAPORATNE COOLER VALIDATION
wi�h comply wirh such provisinns or this permit shall 6e
deemed revoked. FURNACE: FAU_GRqVITY
� IICENSED CONTRACTORS DECLARATION FLOOR BTu U�
I hereby affirm that I am licensed under provisions of Chopfer 9 - SUSPENDED UNIT_
'(commencing wifh$ecfion 7000)a(Division 3 of the Business NEATER: WA��
ond Professions Code,and my license is in full fo�ce ond effect. - - - a
Inlets & Outlets p p O ,
litense Number�6860? Lic Class �-$Q ► V r-
IrvineWest 8-8-87 - �
Contrac•or Dme �1 O 2 H A u
❑ �
I am ezempt under Sec. p�an Chetk fee Fi• • • • �$ , y
- B.BP.C.for�his.eason PERMIT ISSUING FEE S �
' I • 1 32,00
Da�e:
Slgnatuie TOTAL FEE Up s tl � 3 Z G Q�
OWNER-BUILDER DECLARATION -- PWN CHECK aaPLICANT - ' .
I hereby offirm fho�I am ezempt irom the Contractoi s License ► t��•2 5`�8 7
�y for the following reoson(SeUion 7031.5,Business and NAME �
__. Iessions Code): �
� � LJ I, as owner of Ihe property, or my employees with AD�RESS � •
wages os�heir sole rompensaifon,will do the work and . -
Ihe strutlure is not inrended or of(ered for sole(Sec�ion C�TY TEL NO.
7044,B�siness ond Proiesslons Code).
OWNEit
❑ I,os owner of Ihe prope�ty,am exdusively mntracting m . ?1 0 a 8 A
with licensed coMractors to mnsirucf Ihe project(Sec• ��� � - - � -
� lion 7044,8usiness and Professions Code). ADDRE55 1 91 MitC}1C11 S011th �• •• • •8
CONSTRUCTION LENDING AGENCY - � � � � -
I hereby aHirm thot there is a constroction lending agenty fo� CITY Iz.Vlri2 Ca 92714 ��'NP714) 660-0660 . I e � ���O
Ihe performance of the work for which Ihis permit is iss�ed CONTRACTOR - IrVj.I12SV2St Htg & Alr e e =
(Sec.3097,Civ.C.1. . _ ....._. . . �._ . _ �.p�.Q��,
AD�RE55 638 Southern Ave. ��- � � � �� .
Lender's Name . . . ... . . ... .. - O$��`8 7 ,
an Orange Ca 92665 rei.N6714) 921-0800 ..,
Lender's Address
I certify thot I hove read lhis applimtion ond state ihal Ihe iIC¢Nse No.- � 466609 .ciA55 C-2�- .� , . . .„._, . . ,,, . _
above info�mation is torretf.I ogree}o comply with oll County . .
- ordinonces ond Stote laws relaiing to building 2onstruction, _ � : , , __ , . . . .. ._ _ ,
and hereby aulhorize represenlafives of this Coonly�o en�er - - � � � �
upon rhe above-mentioned property for inspection pu�poses. SEE REVERSE FOR EXPLANATORY LANGUAGE .
B-8-87 • .
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