HomeMy WebLinkAbout1134A (5) �� WORKERS'COMPENSATION DECLARATION �pp�ICATION FOR PERMIT �
! her:b.;nffi;�; !ha! I Fave c ,�:ficd'a of ronsPnt ie=-!{
� insure,or a certifimte of Workers'Compensation Insurante, �
o�a ce�rified copy rhe�eof(sec ssoo,�a6.c.) �aA3eac HEATING - VENTtLATING - AIR CONDITIONING °�
�� CE-818(REV.70/81) - t_,T.�'�
p o l icy No. 1 n�l�,16, Company S�tate FllTlf1 ��j(g� L �� �' etTVP�� �
L J C erti4i e d c o p y i s h e r e b y f u r n i s h e d. q'g'� � ������Y OF LOS AivG€�€S J'ViliF iiii Bv�LDING ANG 3i��e�
� Cert�ied copy is filed with�he county buiiding inspeo- FOR APPLICANT TO FILL IN sU�lowG
. tion depariment. ADDRE55� ZOHO2 Eas'c High Coun�.ry Drive
. (PRINT OR TYPE DNLY)
� Dote � �3 �� qppi;canr - T �ocnurr Diamond 3ar
NO. TVPE OF APPLIANCE OR EC;UIPMENT FLE
� CERTIPICATE OF EXEMPTION F M WORKERS' -� NEAREST �
COMPENSATION INSURANCE CeOSS 57.
� ABSORPfION UNIT,8TU
(This section need not be compleled if the.work Involved by . oisreia No. aaocesseo ev
ihe permif is For�one hundred dollars(;100)or less.) � � �
i certify iha+in ihe performance of the wnrk tor which ihis A�R HANDI,ING UNIT,CFM
� I
permit is iss�ed,I shall�noi employ any person in any manner
so as to become subject to the Workers'Compensation Laws. gOi�ER,-RiU aPaeova�s oare iNsvecroe�s sieNaTuee
� Da�e Applicani j CUMPRtS50R,6TU IO OO ROUGH .�1� � �
� NO?ICE TO APPLICANT: If, after making ihis Certificate of venli��AiiON SVSTEnn F�NAL �
� Exemption, you should 'become subject to the Vdorkers` --- - �
Compensafion provisions of ihe Labor Code,you musf for�h- EVAPORATivE COO�ER VALIDATION
wi�h comply with such provisions or ihis permii shall be
deemed revoked. FURNACE: FAU�_GRAVITI'
� IICENSED CONTRACTDRS DECLARATION FLCOR aiu 10. 00 .
I hereby affirm that I am Iicensed under provisions of Chapter 9 SUSPENDE� UNIT
HEATER: WALL �
(mmmencing with Section 7000j of Division 3 of ihe Business � �
ond Professions Code,and my license is in full force and effecl� � �
� � T 7 ,r (�
License Number— �68699 ����Class s_�� - , � �
Conrracror rrvineTidest Date 7-23-�� �
O
� —- ._ _ � - � ?I;.rl �
I am ezempt under Sec. �
Plan check fee �a.
s�
B.&P.C.forthis reason� 8�' � °� " �C; �
PERMIT ISSUING PEE S ip 5p 3 t � �,
Dote:
Signatvre TQTAL FEE �L,�P ^�
OWfJER-BUII�ER DECLARATION PIAN CHECK APPtICANT � . � � - " ""
I hereby affirm fhat I arri exempt from the CoMroctor's License ► �. -.-y n r; �
Law for ihe following reason �Sedion 7031.5,$usiness and NAME ��--�''' �' �
"Professions Code): .
❑ I, as owner of the property, or my employaes with ADORESS � _
wages as iheir sole compensafion,will do ihe work and
the shucture is not intended or offered for sale{Section CiTY iEL NO. .. .
7044,Businass and Professions Code). � _
OWNER y�illiam L on Com an
❑ I,ps owner of ihe property,am exclusively contracting �' p Y � �
wi�h Ilcensed conhactors to mnstrott ihe projed(Ser MAIL � -
tion 7044,Rusiness and Professions Code). � ADDRE55 19 Corporate Plaza �
CONSTRUCTION LENDING AGENCY - ��T� Newport Beach 9266QEL NC(�.714) �33-3Fi� -
I hereby affirm ihol ihere is�consiroction lending agency for ► �
� the performance ot the work for whith ihis permit is issued CONTRAC70R
(Sec.3097,Civ.C.). t & �it
lender's Name . � AL70RE55 SOA't.r10�ri AVO. �
Lender's Address ��iy Oran e Ca 92605 TE�.No.(714) 921—Q8 0 .
I ceHify that I have read this application and state that the u ENSE No. 468fi09 a455 C-20
� a6ove information is correct.I agree to mmply with a�l County � � _
ordinanws and State laws relqtiny to building construrtion,
and hereby authorize represenfaiives of ihis County to enter
� on thc above-m�ned property for inspettion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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