HomeMy WebLinkAbout1201A WORKERS'COMPENSATIONDECIARATION �. " APPLICATION FOR PERIYIIT ,t �
I hereby afiirm Ihal I have a certificate of consenl lo self 'Z�1
Insure,o�a certifimta of Workers'Compensotion Insurance, �bA364c HEATING - VENTILATING - AIR CONDITIONING I
or a certified copy thereof(Sec.3800,lob.C.) . .
voi��y�No&WC604000 epmPo„� Highlands ce-eie�aev,io�ei�
❑ Cerlified copy is hereby f�mished. f'31 COUNTY OF LOS ANGELES BUILDING AND SAFETY
.� Cerlified copy is filed wilh Ihe munty building inspen FOR APPLICANT TO�FILL IN � BUIlo1NG
tlon department. . (PRINT OR NPE ONLY) . ADDRESS
�aie $/13 Aaal��e„� Inland Ht�_ . �ocnurv �' /�
NO. TYPE OF APPLIANCE OR EOUIPMENT . FEE
_ CERTIFICATE OF EXEMPTION FROM WORKERS' - NEAREST n� ✓1
�COMPENSATION INSURANCE - CRO555T. 'V �
(This s�etten n��d not b�eompl�tad if 1hs work fnrolwd 6y AB�RPTION UN�T,BTU Di51Ri�1 NO. GROCESSED BY
1ht permk Is lor ona hundrod dollars(5100)or laff.) � �
I cerlify thol in�he performance of the work for whith this AIR HANDIiNG 11N1T,CFM I if
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permit is issued,I shall not employ any persan in any manner gORER,BN
- so as to becoma subject to the Workers'Compensation Lows. nvar+ovnts DATE INSPEC7045 SIGNnTt1RE —
Da1e /rpplicant I COMPRESSOR,BTU O GO ROUGH ���7
NnTCE TO APPIICANT: If, afler moking this Cerlificofe of VEMILATIONSYSTEM FINAt _ £
f iion, you�should become subject �o the Workers
C.._ ensalion provisions af Ihe Labor Code,you must fo�ih- . EvnPORnT�vE COO�ER " VALIDATION
wilF comply with suth piovisions or this permil shall be � .
deemed revoked. NRNACE: FAV VI
LICENSED CONTRACTORS DECLARATION I FLOOR BTU �
I hereby affirm thot I om licensed�nder provisions o(Chop�er 9 HEATER: SUSPEN�ED UNIi_ _
�(commencing with Section 7000)of Division 3 of the 8usiness - N`A«
and Profess�ons Code,and my license is in fvll force ond effed. � � �'
� S a
licensa Number 448349 Lia Class G'LO , �
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Contractor TT{�gp� ��.g. Date $�1� - - - O
� _ �
I am e:empr�nder Sec. w
Plan check fee N
8.8P.C.for�his reasnn PERMIT ISSUING FEE S z
' Date:
Signature
TOTAL FEE
�� OWNER-6UILOER DECLARATION GLAN CHECK AVPlIC.4NT .
I hereby afiirm ihal l am exempt irom the Controttor's Litensa . � �� 2(�� �{ �
Law for ihe following reason(Sedion 7031.5,Business and NAME � . . , �
Pf'r^ofessions Codej: " r�•�. a • •$
! ll, as owner of the p�operty, or my employees with ADDRE55 . -
�,J wages os their sole compensotion,will do rhe wcrk end . I • e�?Q,7�
the shucture is not intended o�bffered fo�sale(Section CITY �7EL NO.
7044,8usiness and Prafessions CodeJ. •� •4 9,7 5=
OWNER Bramalea California, Inc. U
❑ I,as owner of the property,am exclusively cantracting � . .- . � 0 9�2 S—S 6
with.licensed contradors to construd the projeU(Sec- qDDRESS 3151 Airway Avenue, Suite N .
tion 7044,8usiness and Professions Code). �
CONSTRUCTION LENDING AGENCY � CiTv COStH Piesa� � � ����No.� � - �- � .
. I hereby affi�m that�here is a consrruction lending agency for
the performonce of the work for which Ihis permit is issued CONTRACTOR Inland Heating,� Ine. � � ��-
(Sec.3097,Civ.C.). ..�_.... ..... _ . .. .
. -.
ADDRE55 1696 Co�nerce Street ���� � �� ` ' - � ' ' � � -
� lender's Name .
aTv • Corana 'E�.^'o. 734-4540 -
Lender's Address
STATE IIC.
I cerlify thot I have read this application ond sta�e thal the ucer,se No448349 -.. -. .. anss .C-20. __... ...... . . .
abova information is mrrect.I agree 10 tomply with all County . . � .
ordinanc s and State laws relating to building tonstruUion, . _ _ _ _
and h r y authorize representatives ot this Co nty to en�er . . " - �
up h a -menrioned properiy for In:p�t n purposes.. SEE REVERSE FOR EXPLANATORY LANGUAGE_ .
�� l.
Signa�ureofApPltcani�orAgent Date - . . .._.._. . . ... . .. . ....._. . _ .. . ,
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