HomeMy WebLinkAbout1198A 1199A WORKERS'COMPENSATIONDECLARATION qpp��CATION FOR PERMIT �
I hereby offirm that I have e tertificote of consent to selF - � �\
ins�re,or o certifica�e of Workers'Compensa�ion i�5�.o��e, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec.3800,lob.C.) 76n36nC-
CE•81B(REV.10/81) -
�cy No. BWC60400@omPa„y Highlands
Cert�fied copy is hereby furn�shed. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed wilh the county building inspec- FOR APPLICANT TO FILL IN eU�tD�NG
tion deportmenl. , (PRiNT OR TYPE ONLY) ADDRE55
Date HIL3 Applicont Inland Ht�. � - LOCAON r a �
NO. TVPE OF APPLIANCE OR EQUIPMENT FEE
- CERTIPICATE OF EXEMPTION FROM WORKERS', � NEnREST /�
� COMPENSATION INSURANCE CROSS Si. - l
(Thb sadion naed nof be complsled if}he work involved by ABSORPTION UNIT,BTU oisraic�r+o. vcocEsseo ar
tho pormil Is for ono hvndred doliors(5100)ot I�ff.) AIR HAN�LING UNIT,CFM� I
I certify that in the performance of Ihe work for which lhis �
_ permit is iszued,I shall not employ any person in any manner gOILER,BTU —
so as to betome wbject to the Workers'Compensation Laws. / avvaovnis ont¢ INSPECTOR'S SIGNATURE
Dale � Applicanl � 1 COMVRESSOR,BTU ��J ROUGH �ZdE
P'^T CE TO APPLICANT: If, after moking thi5 Certificota of VENTILAT�ON SYSTEM FINAI ,�(-�
�o
' plion, you shoold become�subject to the Workers' �
. C..,,pensolion-�rovisions of fhe Labor Code,you must forlh• EVAPORATIVE COOLER VAIIDATION .
with tomply wilh s�ch provisions or lhis permil shall he
deemed revoked. � � � - ` FURNACE: FAU VI1V I Q
LICENSED CONTRAC70RS DECLARAiION . 1 FLOOR BTU
I hereby affirm thof I om licensed under provisions of Chapter 9 HEATER: SUS7ENDED UNIT_
'(commencing wilh Section 7000)of Division 3 of 1he B�siness WA« � . }
and Professions Code,and my litense is in full force and eifed. � - _ p,
License Nombe� 448349 i;�.eia„ C—Z� . V
a
eo�ao��o.Inland HEg. pate SI13 �
v
❑ I am exempl under Sec. "� . . - � W
Plan check fee °-
8.&P.C.for this reoson- � - � y
PERMIT ISSUING FEE S Q �
Z .
Dale:
TOTAL FEE �
Signature
OWNER-BUItDER DECLARATION � rlaN CtiECK n7vuCnnli � . �
I hereby offirm ihat I am ezempt from fhe Contratlor's License - , . � (�
Lew for Ihe following reason(Settion 7031.5,Business�ond NAME . � � ��
- Profeuions Code): � -- - � � . � � �
ADDRE55 �
.�I, as owner oi�he property, or my employees with ,± �
.J wages as their sole compensation,will do the work and ��7v TEt.NO. �
ihe slructure is not in�ended or oifered for sale($etlion - J �
7044,8usiness and Professions Code).� � � �'9� .7 5
. OWNER gramalea California, Inc.
❑ I,as owner of the property,am exclvsively coNrading �i . s a. '7�. Jc�
with licensed conlractors to construU 1he project(Seo- qDDRE55 3151 Airway Avenue, Suite N � -
�ion 7044,Bosiness and Professions Code). � �
CONSTRUCTION LENDING AGENCY �� � �� � � � �- - � O"2 5�8�'
I hereby affirm Ihat there ii a construclion lending ogency for ��� COS tfl 21esa � T���No. .
the per{ormante of the work for which this permit i5 i55ued ' CONTRACTOR ► • =1 1 9,9 A
(Sec 3097.Civ.C.). � � . � ' Inc. ..---- . . . _ �{.e .e.�.�8 ...
aooQess 1696 Commerce Street -- � -- �=
Lender's Name
aTv. Corona TE�."0 734-4540 . �' "(�9.7 5
Lender's Address �
STATE LIC. e e �[�9,f J�
I certify Ihat I hove read this applitalion and stale Ihol Ihe. LICENSE NO,��FG$3C19 C1A55 - (J-20 �- � � � � -- �- � -� - - � - -- -
obove information is correct.I agree to comply wiih all Counry D 9 c 5—II 6
o�dinences a State Iews�eleting to building construdion,. _ . . . , , _ _ _ . _ . __ .__
and he b horize representa�ives of this Cou y ro eNer . � � � '
upon t v - rione�d p�ro/�perry for inspe pr�urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE .
t/Y � �S � - . . . .. _.... . . . _. .
Signarure of ApPlimm or Agent � Doie -. -. . . � . . ... . -.. �_ ... ... . .. . .
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