HomeMy WebLinkAbout1214A WORKERS'COMPENSATIONDECLARATION . API�LICATION FOR PERMIT �
I hereby offkm that I have a ceriificate of consent to self � -
�nsore,or a cer�ifita�e of Workeri Compensason Inwrance, ;bA3a�c HEATING- VENTILATING - AIR CONDITIONING ��
or a certified copy thereoi(Sec.3800,Lab.C.) �_g�g(gEy.io/el) � � -� � -
a�y NoaWC604000comPe„y_ Highlands
Cer�ified topy is hereby fumished.- 1�, COUNTY OF LOS ANGELES� BUILDING AND SAFETY
�X Certified topy is filed wirh the county bullding tnspec- FOR APPLICANT TO FILL IN BUIIDING
tion departmenf. (PFiINT OR NPE ONLY) ADDRE55
Do�e 8/13 Applicant"� III7gRd Htg. � iocnun' 'rr
� NO. TYPE OF ACPLIANCE OR EQUIPMENT - FEE
. CERTIFICATE OF EXEMPTION FROM WORKERS' - NEAREST /�
- COMPENSA7ION INSURANCE CROSS 5T. Id— �
(This satflon ne�d not 6a compl�tod 1(the work Inrolved 6y ABSORPTION UNIT,BTU D�SiRICI NO. PROCESSE�BY
fhe permif is for one handred dol�ere(5100)or less.) qIR HANDLING UNIT,CFM � � O ' �
I certi(y Ihat in 1he perfarmonce of 1he work for which this
permit is issued,I shall not employ any person in ony manner
— so as fo betome subjecf to the Workeri Compensalion laws. BORER,BTU aPvaovnis DATE INSVECTOR'S SIGNAiURE —
Date epplicont � I COMPRESSOR,BTU � �� V(l ROUGH `��f� �
NMjCE TO APPLICANT: If, afrer making this Certifitate of VENTILATION SYSTEM FINA� � �L� �
F �tion, yo� should become subject to rhe Workers'
C._rensotion prOvisions of the Labor Code,you must forth• EVAFORATIVE COOLER VALIDATION
with comply with svth provisions or Ihis permit-sholl be
deemed revoked. ' FURNACE: FAU GR Y
� � LICENSED CONTRACTORS DECLARATION - FLOOe . BTU
I he�eby afiirm fhot I om Iicensed under provisions of Chapter 9 SUSVENDED UNIT_
HEA7ER: WA��
'(commencing with Section 7000)of Division 3 of the Business � � � �
and Professions Code,and my license is in full force and effecf. � �'
3 r?`�` S °'
litense Number ��8349 Lic.Closs /`—'7!1 - � - _� ► �
lJ
RY
ConrraUor Tnland Ata_ Daie $�13 � O
� u
I am e�empt under Set. „ W
Plan check fee a
0.8P.C,for ihis reason' _ PERMIT ISSUING FEE S Q ?
Dafe:
59nature TOTAL FEE
- OWNER-BUII�ER�ECLARATION PLAN CHECK APttICANT '
I hereby affirm rhat I am exempt from the Conrracror's License � . ,
Law for the following reason(Section 7031.5,Business ond NaME. - - .
Prrofessians Code�: . , -
I �I, as owner of 1he property, o� my employee5 with aDDRF55 ' tt`� 2�'�A
wages as thcir solc compensalion,will do the wcrk end CITY TFt.NO. ' 'p '� ',
� the siroctme is not intended or offered for sole(Section
7044,Business and Professions Code). . I ���5�2 J�
OWNER Bramalea California, Inc. � �
❑ I,as owner of the property,am e�clusively contracting
with licensed conlroctors to conslr�cl the project($ec• DDRE55 �A °���P 5�
tion 7044,Business and Professions Code). �
CONSTRUCTION LENDING AGENCY CITY - COSC3 Mesa � re�.No.� � - - � 0'u 2 5—8 6
I hereby offirm tha�Ihere is a mnstrutlion lending agency fo� .
ihe performonce of Ihe work for whith ihis permil is issued �pNTRAROR Inland Heating, TI1C. - � ' , '
(Sec.3097.Civ.C.). � - . ._ . . . �
. .— -'._ .. .__
� � ADDRE55 1696 Co�erce Street -- � � �� �-- - � � � � � - � � �� - --
Lender's Name
CITY . _ TEL.NO.
Lender's Address — � � �� �� � -� � � - -
I certify ihol I have reod this applicofion ond smte thm ihe � i c�rise rio. 448349. .. . ciA55. C-20 . .
.._. ..
obove information is correcf.I agree to comply with all County . - � � ,� - �
ordinonces a d Srare lows retoiing fo building consirucrion, _ . � � .
and h e y uthorize rep�esenfo�ives of ihis Co nty to en�er � � � � � �- - . '" - - � �� ��
upon e e- en�ioned propeny for insp� i n urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�
Signai e of Appli<ont ar Agent � � Da1e � -.. �. . - . . . .. ... . .. . . ... . . . .
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