HomeMy WebLinkAbout1196A WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PERMIT �
I hereby af(hm that I have a certifita�e of consen�to self �
insure,or a certifim�e of Wo�keri Compensation�nsurance, 76A364c -' - HEATING - VENTILATING - AIR CONDITIONING ��
ar a cer�ified copy ihereof(Sec.3800,Lab.C.) �.g�8(REV.IOi81) - � - � '
��,No BWC6040�mPa�Y Highlands
Cer+ifted copy ts hereby furnished. COUNTY OF LOS ANGELES- . BUILDING AND SAFETY
..� Certi(ied mpy is iiled wiih the covmy bu�lding�nspeo- FOR APPLICANT TO FILL IN� eU�loiNG � � �
tion depaftmenf. (PRINT OR TYPE ONLY) . /+DDRE55
Do�e S�-� APPlicanl—�� h�att�s �ocnurv (Q
. g NO. NPE Of APPLIANCE OR EQUIPMENT - FEF
CERTIFICATE OF EXEMPTION FROM WORKERS' - NEaREST �
COMPENSATION INSURANCE � - CROSSST. - �
' (This sectton naad nol ba wmplatad li the work fnvolved 6y ABSORPTION UNIT,BTU DISIRICI NO. VROCCSSfD BY �
the permif is Ior one hundred dollors(SI00)or lass.) q�R HANDLING UNIT,CFM � � ' ��
I cerfify that in the perfo�mance of�he work for which this
permit is issued,I shall not employ any person in any monner � gpllER,BTU
. so as to become subject to the Workers'Compensation laws. nwaOvmS onre INSFECTOR'S SIGNAfURE
Dote /+PPlicanf
1 COMPRESSOR,BTU �i�L OOO lO OO ROUGH 2•lrLl
N(�7�E TO APPLICANT: If, after moking Ihis Certificale af VEMIIATION SYSTEM FINAL � � �
F tion, you should become subject �o the Workers'
C._ ensalion provisions of the lobor Code,you must forih- ¢yqppRqtrvE CooLeR VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. � FURNACE: FAU��GRt�V�TY,,.,�� � � '
� LICENSED CONTRACTORS DECLARATION 1 FLOOR BTU�S2�llSl�_ LO OO •
I hereby affirm thot I am li[ensed under provisions of Chopter 9 MEATER: SUSPEN�ED UNIT_ "
'(commencing with Section 7000)of Division 3 of the Business Wntt �
and Professions Code,and my license is in full force ond efiett. � � }
11 Inlets and Outle s
a
l�cense Nomber 44R349 Lia Closs C-20 , V
a
Con�roctor Inland Htg. ooie R/13 O
❑ I am exemp�under Sea , , � oi
Plan check fee n.
B.&P.C.for this reoson� N
PERMIT ISSUING FEE S 10 50 ?
Date:
Signature TOTAL fEE . 49 75
OWNER-BUIIDER DECLARATION PLAN CHECK APMICAM
I he.eby aifirm ihot I am e:empl from fhe Contractor's License � � � - .
lpw for the following reoson(Section 7031.5, Business and NAME . . � �
Professions Code): -
r�l, az owner of the prope�ly, or my employees with AODRE55 :� � 9.6 A
. /woges os ihelr sole compensotion,wi;l do iha wcrk and . . .
the structure is not intended or offe�ed for sale(Section CITY TEL.NO. Ff• •t5
7044,B�siness and Professions Code). .9 e 0,
❑ I,os owner oi Ihe p�operiy,om exclusively conlracling OWNER gramalea California . 1 4 7 5
with litensed contro[rors 7o consfrucl Ihe projetl�Set- N'A�� +��4 9.7 S�
tion 70G4,Business and Professions Code). ADDRESS 3151 Airwa .Avenue, SuiEe N _
CONSTRUCTION LENDING AGENCY GTV � "COSCd M2Sfl � TEL.�NO. - " � � �- D H.2 5"8 6
I hereby affirm that�here is a consrruc�ion lending agency for
the pe�iormance of the work for which this permit is issued CONTRnCTOR -"� � � �� �- - -� �
(se�.soa�,C��.C.). Inland Heatin Inc.
nooRess 1696 Commerce Street
Lender's Name �
arv Corona - - TEi.No. 734-4540 -- -
Lender's Address � � ' �� �-
STATE IIC. . �
I certify Ihal I o e read this oppGcafion�and stote that Ihe uc�Nse No. 448349 CLASS (�,-2� � � � � - - . _
above info ma ori is correct.I agree to comply with all County .
ordinanc State lows reloting 10 bullding conslruUion, . �
and here thbrize represeNaiives of this unty to eMer � � � ' �� � � � - - . "� �
upon the b e t�oned proper�y for ins e tion purposes. SEE REVERSE FOR EXP4ANATORY LANGUAGE
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