HomeMy WebLinkAbout1200A WORKERS'COMPENSATIONDECIARAiION APPLICATION FOR PERMIT �
, I hereby eff'Km tha�I have a certificate of consent to seif � 23
insure,or a tertifico�e of Workers'Compensation��:o.or+ce, ����� _ - . . �-- HEATING - VENTILATING - AIR CONDITIONING
o�a cerlified mpy thereo((Sec.380D,Lob.C.) �E-81e(REV.�l0i81) � � �� - �
Polity No.III�TCGO4OOOCompany Highlands I � . . ,
� CeNified copy ia he�e6y f�rnished. 1 y� COUNTY OF LOS ANGELES � BUILDING AND SAFETY
� Certified topy is filed wilh ihe county bvilding inspea FOR APPLICANT TO FILL IN - - BU�L�ING Q ' �� ,n,�
fi0n deportment . � ADDRE55 (.,(i(,c�
S�13 . (PRINT OR TYPE ONLY)
Date Applicon�_ III13Ad HC�. iocnurr �'
NO. TVPE OF qPPLIANCE OR EQU�PMENT FEE
. CERTIFICATE OF EXEMPTION FROM WORKERS' NEaeE57
� COMPENSATION INSURANCE � CROSS ST.
(Thls sedion nood not 6e eompleted if 1he werk Involved by ABSORPTiON UwT;BTU o�sra�a r+o, vaocEssco er.
th�parmit is for ona hundrad dollars(5100)or lacs.) qIR HANDLING UNIT,CFM
I certify that in�he performance ot the work for which this �O
_ permit is iss�ed,I sholl not employ any person in any manner �
so as 10 become sobject to the Workeri Compensonon Laws._ eoReR,BTu AFGROVAfS onr¢ MSVECTOR'S SIGNATVRE —
Da�e ApplicoM � COMORESSOR,BTU �Z�� OD ROUGH ,�_�
Nf�i10E TO APPLICANT; If, after moking ihis Certi{ita�e of VEN71tATIONSYSTEM FINAI .� .
E }�tion, yo� should become subject to the Workers' �
C._.(ensarion p�ovisions of ihe Labor Code,yau musl lo��h- EVAPORATiVE COOIER VALIDATION �
wifh comply with s�ch provisions or this permil shall be
deemed revoked. � FVRNACE: FAU_yRAV1T' .
� LICENSED CONTRACTORS DECLARATION � FLOOR eiU i YD��Y�(� - QQ �
' I here6y offirm thal I am licensed under provisions oF Chopter 9 SUSPENDED UNIT— �
HEATER: wA��
'(commencing with Sedion 7000)af Division 3 of fhe Business
- and Professions Code,and my license is In full forte and effect. y /� �'
7 �"1 Q
l�cente Number 448349 ���.Class C'-20 . � �� � 11
a
Contracror.Inl and�Nh g_ Daie��1� � � , O
F-
❑ I am exempt under Sec. .. .. . . W
Pldn check fee N
B.BP.C.tor ihis reazon PERMIT ISSUING FEE S �
Dofe:
Si9nomre TOTAL FEE
.OWNER•BUILDER DECLARATION MAN fHECK APMiUNT �� G Q O A
� I hereby aifirm fhat I am ezempt from the Contracto:s License �
Law for the Tollowing reason(Seclion 7031.5,Bosiness ond NAME . � �o •• • i 8
PrfO�C55iOt15 CO()B�: - �
I 11, as owner of Ihe properly, or my employees wilh A�DRESS � +�119,7 5
__f wages as their sole compensaiion,will do�he work and
Ihe strvUure is not iniended or o(fered for sale(Set�ion CiTY TEL NO. � �e�e 4 9.7 5 c=i
70d4,B�siness ond Pro(essions Code�.
own,ee Bramalea California, Inc.
❑ I,as owner of the p!operty,am endusively mnlrading . O a P S-S G
with licensed convactors�o conshuct the project(Seo- �"�'�� -
tion 7044,Bosiness and Professions Code). , ADDRESS 31
CONSTRUCTION LENDING AGENCY CITY �COStB hiesa TEL.NO. � - �
I hereby aifirm thot ihere is a conslrucfion lending agency for
the periormonce of fhe work far which this permil is issued - fONTRACTOR �"� . - �
�sac.3ov�,c��,c.). -Inland Heating, Inc: _
� � � ADDRE55 1 6 Commerce Street " � � - -- � � -� � � - � • - �
Lender's Name
atv Corona rei.No. 734-4540 _ .
lender's Address �
I certify thot I have read Ihis applicotion and Sto1e thpl lhe� LICENSE NO. �F�f83�i9 �� QASS� C-2� - _- _. . . . __ ... .
obove informotion is correcl.I agree to comply with all Co�nty . �
ordinances d Sta1e laws relaling to building construdion, �,
ond hereby ou�horize representalives of this Coo y to eNer � . - � � � ' - � -
upon t m tioned propeny for inspe ' purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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