HomeMy WebLinkAboutNo Permit Number (9) WORKERS'COMPENSATIONDECLARATION � . APPLfCATION FOR PERMIT � �
I here6y affhm that I hove a certi(icate of consent to self
insure,or a certificoie of Workers'Compensation i�s�.a��e, - � ���� ��. HEATING�-�VENTILATING - AIR CONDITIONING
or a te�tified mpy thereof(Sec.3800,lab.C.) � 76A3aaC . . .
- CE-B18(REV.10/81) - � -� - - � - � .
P❑olicy No.��I O88$Saompany �� Ins. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certiiied copy is hereby furnished.
� Certified copy is filed with ihe county building inspeo- FOR APPLICANT TO FILL IN BuiIDiNG
fion deporfinenl. � - � ADDRE55 1415 S. Lemon v n
. (PRINT OR TYPE ONLYJ
Dafe 8'4'83 ��Applicant Santiago� A/C � LOv`"T''TR. 30893-A ot 64
. NO. TYPE OF APPIIANCE OR EOU�PMENT . .FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' -. NEAREST
COMPENSATION INSURANCE � CROSS 5T.
(Thls f�cNon n��d not 6a complat�d ff fh�work�nrolv�d 6y �+BSORPT�ON UNIT,BTU OiSiRiCT NO. FRpCE55E0 BY
tho perml}fs tor ona hundrod dollars(;100)or lass.) � � � �t„ �
�cerlify ihat in the pe�formance of tFe work for which lhis AIR HANDLING UNIT,CFM ' `,. `
permit is issued,I shall not employ any person in any manner - �
so as to become subject to the Workers'Compensalion Laws. BOILER,BTU AVPRpVALS Dare S�ECiOR'S S�GNATURE
� COMPRESSOR,BTU �� ROUGH '
Date epplicant �
NOTICE TO APPIICANT: If, after making this Certificate of VENTILATiON SYSTEM fINAt l.� � � /��
Ezemplion, you should become subject lo the Workers' � � �
�Campensation provisions of Ihe Lobor Code,you most forih- EvnvORnT�vE COOtER . VALIDATION -
�� with comply wiih such provisions or this permit shall be � � � ��- ,
deemed revoked. � ' � fURNACE: FAU AVITY �p ' -
IICENSED CONTRACTORS OECIARATION . � FLOOR e U ��
� I hereby affirm fhot I am litensed under provislons of Chopler 9 . HEATER: SUSPENDED UNIT_ �
�(commenting with Settion 7000J of Division 3 of the Business ' wA�� �
and Professions Code,and my license is in full force and effecl. � �"" � 5� a
� Q
license Number 269496 lia Closs G20 - , V
�co�ao�io� Santiago A/C Dote 8-4-83 � F. '
0
�� . �ll ;3A
I om exempl unde�Set. a
Plan check fee ;j. .$ N
B.BP.C.ior ihis reason' pERMIi ISSUING FEE S �j0 ?
Dare: I'• •5 5 0 G
5gnoru�e TOTAL FEE 55�� �.o r = '
•;»00� �
� OWNER-BUIIDER DECIARAT10N PLAN CHECK APPLICANT .
I hereby affirm ihal I am exempt from�he ContraUor's Ucense . � ��� (,—ji:�
Law for the following reason(Sedion 7031.5,Business and NnME - � . ,
ProfessionsCodeJ' -� . . � ,
❑ I, as owner of the property, or my employees wilh ADDRESS ' �
I wogzs es 7hzir sc!e ccmpenic!icn,wi!I do.'he we�k=^a CITY - TEL NO. . �
1he str�cture is not intended o�offered fo�sale(Section .�
7044,Business and 7rofessions Code).
owNea Presle
❑ I,as owner of the property,am exclusively contiatting
with licensed connoctors m mnstroct the projett(Seo- � ��� � : - -- -�
AD�RE55 4600 Cam us Dr
� �ion 7044,Business and Proiessions Code�. �
CONSTRUCTION LENDING AGENCY �- atv - �- - - - iet:Ho. - -� ----- --
'I heieby oifirm thar�here is a mnstruUion lending agenty 1or NeW ort Beach � � '
the performonce of ihe work for whith Ihis permif is issued - - �OMRACTOR - - '
�(Set.3097,r...e.�. . - Santia o Air�Conditionin - .._. . . ,.
lender's Name NOne ADORESS . SOO W. Rowland � - � .� - - - � �- - - � - �- -
. .. CITYSQf1tO Afl _ . . . TEL NO. . ._ _ . _. .. _
Lender's Address '
� STATE LIC.
I certi{y that 1 have read this applicotion ond stote thal the uc�r,se r,o.�269496 CtA55
above information is correct.I agree to comply with all Couny .
ordinonces and S�a�e laws relating�o building construction, � � .
and h eby aoihorize re sentatives ot this County fo enter - �' �' ' --
up the abave-menr' ed �ope tor inspection purposes. SEE RE4ERSE FOR EXPLANATORY LANGUAGE
8-4-83
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