HomeMy WebLinkAbout1027A WORKERS'COMPENSATIONDECLARATION APP�,ICATION FOR PCRMIT �
1 hereby affhm that I have a cer�ificate of consent�o self
insixe,•or a teriifim�e of Workers'Compensotion Insurance, �6/+3eaC NEATING - VENTILATING - AIR CONDITIONING
. oi a cenified copy�hereof(Sec.3800,Lab.C.) �E-818(REV:10/81) � - - - - �- � -
POollcy No. 1021516c'ompany State Fund PH�3
Cer�ified copy is hereby furnished. BLDG$�f� COUN7Y OF LOS ANGELESJOB# 1208 BUILDING AND SAFETY TR# 42533
� Certified topy is filed with the caunry building in:pea FOR APPLICANT TO flLl IN BU�tDING /
fion deparfinent. (PRINT OR TYPE ONLY) ADDRE55 +�
Do�e o—a—a�Applitant ����T� Diamond Bar
NO. TVPE OF AP%.IANCE OR EQUIPMENT . FEE
CERiIFICATE OF EXEMPTION F WORKERS' � NEnREST
COMPENSATION INSURANCE CROSS St.
(Thle�attion na�d not be eompl�lad ff Ihe work involvad by ABSORPTION UNIT,BTU DISTRICT NO. PFpCES$ED BY
�he permft Is for one hundred dollars(Sloo)or less.) q�R HANDLING 11Nli,LFM � /'� � �
� I certify Ihal in the performance af ihe work for which this V Q On �
permit is issued,I shall no1 employ any person in any manner gOtLER,BTU —
_ so as to become s�bjeU lo rhe Worke�s'Compensalion Laws. nvruovnis DATE INSKCTOR'S SIGNATURE
� 42,000 �j
--� . oPP�i�a�� � COMPRESSOR,BTU [� ROUGH � nvti��
�s"' �ICE TO APPLICANT: If, affer making Ihis Certificate of VENTILATION SYSTEM FINAL � '
Exemption, you should become subject to ihe Workers'
Compensa�ion provisions of rhe Labor Code,you musf forth- EVAPORAtIVE COOtER VALIDATION
with temply wi�h su:h previsior.s or this permit sholl ba ,
deemed re�oked. � FURNACE: FAU_GRAVIN - � �
. � IICENSED CONTRACTORS DECL4RATION � iS ftaOR B7u_Fi,nan ��) O �
I hereby offirm thof I am licensed onder provisions of Chapter 9 SUSaENDE� UNiT_ -
. '(commencing with Setfion 7000)af Dirision 3 of the B�smess HEATER: wA��
and Proiessions Code,and my license is in full force and effect. � ' a'
468609 c-20 W O
License Number Lia Closs � � , , tJ
:'� �2.7A �
cono-ac�o� IrvineS�lest Date 8-8-87 , 0
� ❑ I om ezempr onder Sec. _ � � #• • • • •a ua
- Plan check fee y
B.6P.C.for this reason� � 10- 0 � � •1 9 4.5 p Z
PERMIT ISSUING FEE S
Date: TOTAL FEE. � ' ' '� 9 U.5�'--'
. � Signafure � � - -
OWNER-BUILDER DECLARATION rwN CHECK aPauCnNT �.�2�`8 7
1 hereby offirm thaf I om ezempt from the Contractor's License � . . _
�-•q for tha(ollowing reason(Section 7031.5, Business and NAMe - ,
}�.ssions Cod'ej:
`,r�' ��J ADDRESS
� LJ I, as owner of the property, or my employees wilh �
wages as their sole compensotion,will do tha work and
� the s�ruc�ure is not in�ended o�ofiered tor sale(Sec�ion ��TY 7EL.t�0.
7044,Business and Professions Code). OWNER Presley Company
❑ I,as owner bf the property,am ezclusively contmUing
with licensed tontroclors lo co�sfrott Ihe projed(Sec- DDRE55 17991 Mitehell SoUth " �
tion 7044,0usiness ond Professions Code).� '
CONSTRUCTION LENDING AGENCY �iTM rrvine Cd 92714- �i No (714� 660-06 0
I hereby affirm thol lhere is a construcfion lending ogency for �
ihe performonce of the work for which ihis permit is issued COMRACTOR �� � - � ' ' , �
IrvineWest Ht & Air __ . ._
(Sec.309�,Civ.C.�. �- -
no�aess 638 Southern Ave.
Lender's Nome
lender's Address ��TY Orange Ca �92665 tE��"��714)-921-0800 �- -� --- - -- _ . _ ... _
I cer�ify�hal I have redd�his applim�ion and sta�e that the uceNse No. 468609 cLnss- e=20 _ ., , _. . , . ._, _ .
a6ove information is covect.I ag�ee�o comply with oll Counry , , -
ordinances and Stote lows relating to building tonstruction, , ,
and here6y authorize rep�esemolives oi this Counfy�o enier �� � - ���� '"" -�- � -
up � e above-me/nrioned properiy(or inspecuon purpozes. SEE REVERSE FOR EXPIANATORY LANGUAGE .
CL 8-8-87�
Siq e of Appliian�or Agem Dete . - . . _. . . . . .. - .._ .._. . . . . . . .
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