HomeMy WebLinkAbout1213A WORKERS'COM7ENSATION DECIARATION �
I hereby offhm thot I hove a certifi[ote of consenl to self APPLICATION FOR PERMIT . ���
insure,o�a ce�rificare of Wo�kers'Compensa�ion�nsurance, �6A3sac • HEATING • VENTILATING - AIR CONDITIONING
or o certified copy Ihereol(Sec.3800,Lob.C.) �CE-BIB(REV,10/81) ' �� � - � � �
O�Y'NoBWC604000comPa�y Highlands .
Certified copy Is hereby fumished. � ��131 COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certifled copy is filed wllh the covnty building Inspeo- fOR APPLICAN7 TO FILL IN BUiLDiNG 1 ��
lion departmenf. � AD�RE55
$�13 IRI.HIld Ht (PRINT Ok TYPE ONIV) �p��ITY
Dara Applicont g'
NO. NPE OF APPLIANCE OR EQUIPMENT � - � FEE
. _ CERTIFICATE OF EXEMPTION FROM WORKERS' NEARESi . � �
. COMPENSATION INSURANCE . cao55 si.
(Tht�s�ction need nof be tomplsled(f fha work Involred 6y ABSORPTION UNIT,BiU DISiRi�l NO. PRp�ESSFD BY
}ha pe�mft If fof ona hundred dollars(S1D0)or loss.� � AIR HANDLING UNIT,CFM ,� I�
I certify thot in the performance of the work for which this V ,� L
- permil is i55�ed,I Shull no}employ any person in any monner
so os fo become sobjecf fo ihe Workers'Compensation Laws. . BOILER,BTU av7aovnt5 onn INSPECfOR'S SIGNATURE ' —
Date applicanl I COMPRESSOR,gTU O GV ROUGH . �� _�-� �j�
NnT�CE TO APPLICANT: If, a(ter making ihis Certifitate of VENTIIATION SYSTEM FINAL y�p.,�� '
F tion, yoo should become subject to ihe Workers'
- �G... ensalion provitions of ihe Lobor Code,you musl forlh- EVAPORATIVE COOLER VALIDATION � �
with comply wi�h such provisions or ihis permit shail be
deemed revoked. � � FURNaCE: F/+U v v -
IICENSED CONTRACTORS DECLARATION FtOOR BTU
I hereby af{irm thal I om licensed vnder provisions of Chop�er 9 • N��R: SUSPENDED UNIT_ - - . .
'(commencing wi�h Section 7000)of Division 3 of the Business wA« , r
and Professions Code,ond my license is in full force and effecl. � � � � a
Licensa Number 448349 i��.ciass C—�� , V
�
Conrractor�l3ri(�$tg- Date R�1 4 . . . . . �
❑ I om exempt under Sec. _ . . .. ' w
Plan check fee a
�
B.BP.C.tor this reoson PERMIT ISSUING FEE S- 16 � —
Da�e:
S�gna�ore TOTAL FEE 5 �"'
OWNER-BUILDER DECLARATION PLAN[HECK APPIiCANT .
I hereby offirm lhot I am e:empl from the ControUor's license � t�1 2 t,3 A
Law ior the following reason(Section 7091.5,Business and NnME �
Professions Code): � {j s+ s • i$
�ll, es own=r of thw properly, or my employees with ADDRESS � '
J wages os their sole compensa�ion,will do the work and I •.5�2 5
the strutture is not inlended or oifered for sole SeUion CiTY TEt.n10.
� 7044,Business ond Professions Code). ( . . . . e s-s j�2 S�
• OWNER gramalea California Tnc.
❑ I,as owner of the property,am e�dusively contracting . O��G S-$G
with licensed conlroctors 10 consirucf the project(Seo DDRE55 3151 Airway Avenue � � . �
� tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY - COSt3 M05d � TEL.NO. �-� -��""-
I hereby affirm thal Ihere is a tontlruclion lending agency for ►
the performonce of the work far which this permi�is issued CONiRACTOR � IR�.Bild HOHC�IIg� TIIC. � - � �
(Sec 3097,Civ.C:). � . ... . . . .. ..
� AD�RESS - TC0 $CrE2C . . . .
Lender's Name
atr Corona re�.No. 734-4540
lender's Address ��
STATE IIC. '
I tertify thol I hove iead�his appiica�ion and state iha�ihe uceNse r,o. -448349 .- anss .C-20 . . . . . . ...... . ... ... . _ .
abave infor afion is correcl.I ogree lo comply with all County , ,
ordinonces d State laws relo�ing to building constroction, _ � .,
ond h r u�h ize representoiives of this C nty to enter ' - - ��� �- �- - � "� �
apo b v m ntioned property for in ion porposes. SEE REVERSE FOR EXPLANATORY LANGUAGE .. _ .
vl—
Slgno re of Appiicant o�Agenl Dafe . . . .. . . ... . . . . _-.. . . . -. .
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