HomeMy WebLinkAbout1212A WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PERMIT �
1 hereby aifirm that 1 have o certifica�e af consent�o self �3
insura,or a cerriicate of Workers'Compensation i�s�.a��e, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy ihereof(Sec.3800,Lab.C.) 76A36aC .
" BjdC604000 Highlands CE-B18(REV.10/Bl)
Paolicy No. Company � �
Certified copy is hereby f�rnished. � 11� COUNTY OF LOS ANGELES . BUILDING AND SAFETY
� Certified copy is filed with the county building inspeo- FOR APPLICANT TO FILL IN BUILDtNG' In �
tion de arfinenl. ADDRESS Y 1
P (PRINT OR TYPE ONLY) p
Da1e 8�13 nppu�or,r. Inland Htg. _ - �ocnuTv L.� (p0 .
. NO. TYPE OF APPLIANCE OR EOUIGMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'. � NEARFSi � .
- COMPENSATION INSURANCE � CRO55 5T.
(Thls t�eften n��d nof b�compl�Nd iF 1h�work Invelvod by ABSORPTION UNIT,BTU DISiRICI N0. �PQOCESSED BV
fhe permif 1�for ona hundrod dotlon(f100)or lois.) � �
I cerfify fhal in Ihe performante oi the work fo�which this AIR HANOtING UNIT,CFM 1 O
_ permi�is iss�ed,I sholl not employ ony person fn ony manner I _
so as to become subject to the Workers'Compensotion Laws. BOIIER,8TU pPPROVAlS DAiE INSPECTOR'S SIGNATURE
Date� �+pplicant ( COMPRESSOR,BTU CYsI`)GD 4 � ROUGH 2��" �
N^T10E TO APPIICANT: If, after moking�this Ceriificate of VENTILATIONSYSTEM F�Na� --' �7
I �tion, you should become subjecl fo the Workers'
G�..� ensmion provisions of Ihe Lobor Code,you must forth- EVnvOaanvE COO�ER VALIDATION
wi�h comply with such provisions or this permit'shall be .
' deemed revoked. - ' ' FURNACE: FAU�G I �D �
� LICENSED CONTRACTORS DECLARATION� FIOOR TU
I hereby ai(irm thot I am licensed under provisions of Chopter 9 HEA7ER: SUSPENDED UNIT_
�(commencing wi�h Section 7000)of Division 3 of the Business WA�� y
and Professions Code,end my licensa is in full Force and effect. �� n O
LicenseNumber GGR4GQ LiaClass C—Z� . . � - , V
�
Controcrorlril�n.i ut�, Dote $�13 . . � O
o "
I am exempt under Sec. " y �
Plan check fee N
8.8P.C.for fhis reason � Z
PERMIT ISSUING FEE S
Dare:
TOTAL FEE
Signature �
� OWNER-BUIIDER DECLARATION PLAN CHECK APPLIfANT. � . '� 2�.Q A
I hereby oifirm thal I am exempt from ihe Conrracror's Licr.nse . � TM a e c .9 Fj
Law for Ihe following reason(Sec��on 703I.5,Business and NAME � ,
Profess�ons Code):� � � - - 1 •��5�2 5
��1, as owner of ihe property, or my employee3 wi�h ADDRE55
-J wages as their sole compensation,wi�l do�he work and CiTY TEL.h10. � • ''`7 a�3�
.�he s�rudure is not imended or offered forsale�Sec�ion
7044,Busine55 and Prolessions Code). -� OWNER O Q 2`�'�8 6
❑ I,as owner of the property,am exclusively contracting ��
Bramalea California, Inc.
wllh licensed mniractors fo mnstruci the project($ec- ADDRESS �,31SI. Aj.Y'W& Aven C lll e IQ -
tion 7044,Business ond Professions Code).
CONSTRUCTION IENDING AGENCY � � CITY - COSCd Piesa Tfl.NO. � � � -
I hereby affirm that there is a construction lending agency for ,
the performonce of the work fo�which Ihis permit is i55oCd -� �p�,�TRACTOR Inland Heating, ZI1C. �
(Sec.3097,Cw.C.J. - - � . . � . .- .. . _ .
ADDRE55 1696 Commerce Street - - � - � - - - - .-� �
Lender's Name
arv Corona ' rei.No. 73404540'
lender's Address
STATE LIC. i
I certify thot I have read this applicatian and state that the uc�Nse No. 448349 Cu�SS C-20 . . _ . .. . .
p6ove info�mation is correct.I agree to comply with all Co�nty
ordinantesR nd Sta1e lows relating to boilding cansirudion, . .
and hereb(6othorize represemalives of Ihis C onty to enter - � �
upo h ov mentioned property for insp� ion purpases. SEE REVERSE FOR EXPLANATORY LANGUAGE
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