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Home My WebLink About1133A (5) ��`- 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$UItDER DECLARATION PLAN CHECK APPLICAN� G"'�'�� I hereby affirm thnt I nm exempt from ihe Contractoi's ticense — , - Law for the following reason (Section 7031.5, Business and NAME . � Prafessions Code;e ----.- . � ❑ I, as owner of ihe properfy, or my emp�oyecs wifh ADDRESS . wages as iheir sole compensation,•,vill do'he work and CITY . TEL NO. - the structure is not iNended or offered tor sale(Section - 7044,Business and Professions Code). � ❑ nWNER I,as owner of ihe proper�y,om exdusively mnirocting- 1�11.�.1dItl L OII COI0.pany wiih licensed contrnctors to<onsiruct ihe project(Sec-� �"�A��- r�nn�oaa,e�s��ess a�d F�ofess�ons Cocle). ADDRE55 19 Corporaie Plaza CONSTRUCTION LEN�ING AGENCY ��?Y N2L�OY'i, BBdCkl g2FiFiQE'�Na 714) g33-360 - I hereby pffirm�ha�ihere is a construdian lending ogency for , - � the performance of ihe work for which this permit is issued CONTRACTOR (Sec.3097,Civ.C.J. „ - ADDRESS Lender's Name___ A YII AV2. � . , - - � � ie�ders Add�ess ciTv Or4nge Ca 92665 TEL NO.{71n� 921-08 0 STATE LIC. i�err�fy rhai i ha�e�ead ir,�s appi��aro��a�d sra,e rhar rhe uceNse No. 468609 ciass c-20 above informntion is correci.I agree to mmply wifh all County - � � �� o�dinonces and State laws relating to boilding construction,_ . - � . and herehy authoriie representotivas af ihis Couniy to enter � , upon the above-mejntio d property for inspedion purposes. . SEE REVERSE POR EXPLANATORY LANGUAGE � ��'w'� 9-94—R� ^.$i^y IV�c G{.�i's��li0i1'JT nC�{E�if . vu.c . . . � � . , � r�Q°i , .a Cr � i � � i k� . � � .. �, , � . ... . . . __ � � ' �, ' � �1' . .. .. . . .. .. . ' .:� . . + � � i � �. 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