HomeMy WebLinkAbout1133A ��`- WORKERS'COMPENSATIONDECLARATION APPLI[ATION FC�R PFRMIT � �
m I herebv affirm that I hnve n a.nfl��eo,.f� �eI4 i�
� ��s��e, o�a�e�,�+��are ai wo�ke,s compPnsauo����sura�ce, �bA364c HEATING - VENTILATING - AIR CONDITIONING d�
� or a certified mpy thereof(Sec 3800,Lab.C.)
CE-81 B(REV.10i87)
� ��V N��Q21-51�+ Company SY_ate Fund r�.�� �C�7;�%.iJ
� Ce�tified mpy is hereby furnished. ?�R# i.OUNTY OF LOS ANGELES JOB# 1111 BiI1L61NG AND SAFETY PH# 4
� Cert4Y¢ed copy is fi�ed wiih ihe couM buildin .
� y g i�spec- FpR APPLICANT TO PILL W sui�o�NG
tion department. n � qDORE55
$ � (PRINT OR TYPE ONLY) � �' _
'� oa�e 7 �3 8� APPi�ca�r � � � �o�urv
Diamond Ba-r
�" NO. TYPE C7F APPLIANCF OR EQUIPMENT FEE
� CERTIFICATE OF EXEMPTION OM WORKERS' rveqaesi
� COMPENSATION INSURANCE Ceo55 ST.
ABSORPTION UNIT,BTU
{This section need nof be complefed if tbe work involved by oi:reicr No. Nuticesseo sv
� the permif is for one huadred dollars(5700j or less.) , - L� ^ �
AIR HANDLNG UNIT,CFM ' J�� �--�
I cerlify Ihat in the performance of ihe work for which ihis ,��
permit is issued,I shall not employ any person in qny manner
so as to become su6ject to ihe Workers'Compensation Laws. eaILER,Biu naPeova�s eqie ibsaeaok's sicNaruue
Dote Applicant 'I COMPRESSOR,BTU � J�O OO RDUGH ' � �
NOTICE TO APPLICAM: If, after making this Certifimte of VEMilAiloN SYSTEM FlNAt'
Exemption, you should bacome subject to the Workers' -
Compensation provisions of the�abor Code,yo�musr fo�ih- evnPoenTive coo�ea - VALIDATION
ith wmply with such provisions or this permit sholl he
deemed revoked Pt1RNACE Pi1U_X.—GRAV�TY
LICENSED CONTRACiORS DECLARATfON � . � - ROOR eTU 1 O 00
I hereby affirm that I am licensed under provisions of Chopter 9 SUSPENDEO UNIT_
'(commencing with Saction 7000)of Division 3 of ihe Business HEATER: WA��
and Professions Code,and my ikense is in ful!force and effect. A�
�._5�j a'
,—flU��TS , f�
License Number���g5�—Lic.Closs ��� - e,a
Conr.ador Irvine4�est pate 7-23-F37 �
�
o _ _ , �
�am exempi under Sec.
Plan check fee ' � `��' �
B.&P.0£or this reason ;t{a e a � e R uf
Date:_ PERMIT 15SUING PEE$ 10 50 �( � e �,,�+;j� ^-
Signarure TOTAL FEE � " " °`%h i�L'���
OWNER$UItDER DECLARATION PLAN CHECK APPLICAN� G"'�'����
I hereby affirm thnt I nm exempt from ihe Contractoi's ticense — , -
Law for the following reason (Section 7031.5, Business and NAME . �
Prafessions Code;e ----.- . �
❑ I, as owner of ihe properfy, or my emp�oyecs wifh ADDRESS .
wages as iheir sole compensation,•,vill do'he work and CITY . TEL NO. -
the structure is not iNended or offered tor sale(Section -
7044,Business and Professions Code). �
❑ nWNER
I,as owner of ihe proper�y,om exdusively mnirocting- 1�11.�.1dItl L OII COI0.pany
wiih licensed contrnctors to<onsiruct ihe project(Sec-� �"�A��-
r�nn�oaa,e�s��ess a�d F�ofess�ons Cocle). ADDRE55 19 Corporaie Plaza
CONSTRUCTION LEN�ING AGENCY ��?Y N2L�OY'i, BBdCkl g2FiFiQE'�Na 714) g33-360 -
I hereby pffirm�ha�ihere is a construdian lending ogency for , - �
the performance of ihe work for which this permit is issued CONTRACTOR
(Sec.3097,Civ.C.J. „ -
ADDRESS
Lender's Name___ A YII AV2. � . , - - � �
ie�ders Add�ess ciTv Or4nge Ca 92665 TEL NO.{71n� 921-08 0
STATE LIC.
i�err�fy rhai i ha�e�ead ir,�s appi��aro��a�d sra,e rhar rhe uceNse No. 468609 ciass c-20
above informntion is correci.I agree to mmply wifh all County - � � ��
o�dinonces and State laws relating to boilding construction,_ . - � .
and herehy authoriie representotivas af ihis Couniy to enter � ,
upon the above-mejntio d property for inspedion purposes. . SEE REVERSE POR EXPLANATORY LANGUAGE �
���'w'� 9-94—R�
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