HomeMy WebLinkAbout1197A � WORKERS•�oMPENSAT�oNOE«ARAT�oN � � APPLICATION FOR PERMIT � � �
I heieby affirm thaf I have a ceniticote ot consent lo self ��
��5�.e,or a cerlificole of Workers'Compensolion InsUmnce, 76Asb4c HEATING - VENTILATING - AIR CONDITIONING
or a certified copy�hereof�Sec.3800,Lab.-C.) . -
roii�y�No.BWC604004eT�„y Highlands �•e�e�eev.io�ei� -
❑ Cerfified topy is hereby furnished. � ,��` COUNTY OF LOS ANGELES. - BUILDING AND SAFETY �
� Certified copy is filed with Ihe county building inspeo- FOR APPLICANT TO FILL IN Bu�tDWG /�
. tion department. ' (PRINT OR iYPE ONLV) ' ADDRESS � � �,j �
oo�e R/13 Applicant Inland Htg. LOCAUTV
NO. TYPE OF APGLIANCE OR EOUIPMEM FEE
CERT�FICATE Of EXEMPTION FROM WORKERS' - NEnaEST }.�
COMPENSATION INSURANCE � CROSS ST. (
(Thls saction navd nol be complated ii fhe work involved 6y ABSORPTiON UNIT,BTU 0151RI�f NO. FWOCFSSEO BY
�tho permif Is for ono hundrod dollars(f100)or less.) ' - � I�
I cerlify that in the performance of the work for which Ihis AIR HANDLING UNIT,CFM
_ , permil is issued,I sholl not employ any person in any manner� -
so as to become su6jed to the Workers'Compensalion laws. BOitER,BTU pGFROVAlS DAfE �NSPEROR'SS�GNAiURE � —
Dale �pplicant � COMPRESSOR,BTU ROUGH � f�-� /�yy�ti
N(�T�E TO APPIICANT: If, af�er moking this Certifitata of VENTIUITIONSVSTEM FINAL ��� `
E tion, yov should become subject �o the Workers' .
C._ ensation provisions of the Labor Code,you musl forlh- FypppRATIVE COOIER � VALIDATION
wilh comply wilh suth provisions or fhis permit shpll be ,
deemed revoked. ' � FURNACE: FAU_ � IT � � �` �
• IICENSED CONTRACiORS DECLARATION I F�OOR eiu O W �
I he�eby affirm thal I am licensed under provisions of Chaprer 9 HEATER: SUSPENDED UNIT_ -
��commencing with Section 7000)of Division 3 of the Business � wALL
and Professions Code,and my license is in full force and etfett.� - . }
a
license Number 448349 i;�.cio,s C-20 , �
8/13 °C
Comrador Inland Htg. Date - . �
F
•❑ I om ezempl under Sec. ' . . . .. w
Plan check fee a
�
8.8P.C.for this reoson - PERMIT ISSUING FEE S —
Da�e:
S�gnmure TOTAL FEE
OWNER-BUILDER DECIARATION PLAN CHECK APPIICANT
I hereby ailirm that I om exempt from the Conlractor's License � D
low for�he tollowing reoson(Section 703I.5, 8usiness and NANE �
1P�r'o�iessions Code): ' � �� � 9.7}�
I I, as owner of the o er ADDRE55 ' . _ � �
1 pr p ty, or my employees with �!a�� • • •a.
�� Jwages as their sole tompensa�ion,will do tFe work and . �
the str�tf�re is not intended or oifered for sale(Section CITY TEL.NO. �
70dG,Business and Professions Code). � � ��9��5
OWNfR Bramalea California lnc.
❑ I,as owner ol�he property,am exdosively controUing a ^ �4 9.7 5 c=i
wilh licensed coNroc�ors lo mnstr�cllhe projetl(Sec- DDaESS� 3151 �'Y'47ay �V2Rll2� $llj.CO N -
t�on 7044,Business and Professions Code). �
CONSTRUCTION LENDING AGENCY - ...._. . .._. - Q .2 S`H b
CITY COStB M2$1� TEI.NO. �"
I hereby affirm thot thera is o mnstruction lending agenty for '
the perfo�monce of Ihe work for whith this permit is issued �ONTRAGTOR Inland Heatin � Inc. � ►_. �
(Sec.3097,Civ.C.). - .... .._ - - . _ . . .
nooaess 1696 Commerce Street -
lender's Name
��TY Corona Tei.No. 734-4540
lender's Address - � -�
1 certif that I have read this a litalion and state ihat the STATE LIC. .
y pp uc�Nse n,o448349 CLA55 . .C.-2� . . . ..... . . _. .._ .,
a6ove tnformo'on is correct.I agree lo comply with oll CouMy . , ,
ordina ces a S�a�e laws reloting to building construction,
and h,eb t or'e represeNalives of�Fis Cou to enter -� - - - �- �--- � � � - ' - � " - - � �-
upon e v • �io�ed propery for inspe�ty purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE . . . ...
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Signaiore oi pplimnt or Agent Da e -- . .. . . . ... .�.. ... . .-. . - . . �
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