HomeMy WebLinkAbout1211A WORKERS'COMPENSATIONDECIARATION APPLICATION FOR PERMIT �
I hereby aff'nm Ihat I have o cerlificote of consent to self - ( 1
insure,or a cerrificate of Workers'Compensotion Insurance, 76A364c " - HEATING - VENTILATING - AIR CONDITIONING �
ar a certified copy theieof(Sec 3B00,Lab.C.) CE•Bte(REV:toiBt) - - �� ��-�-� � � �-- - �
Polity NoDWC604000Company Ai ghl an� �
❑ Cer�ified copy is hereby furnished. 11`7�I COUNTY OF LOS ANGELES BUILDING AND SAFETY
�� Certiiied copy is filed with�he couny building inspet- FOR APPLICANT TO FILL IN . � - BURDING /f�'n
fion deparfinent. . ' (PRINT OR TYPE ONLY� ADDRESS U P 1
Dote R�13 Applimnt I^lan�3 fitg - LOC'4t1N � � .
. NO. NPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEnResr �
COMPENSATION INSURANCE � � - Ce0S5 Si.
(Thi���eHon ndd not 6�eemplNod if Iha work Involvod by- ABSORPTiON UNIT,BTU p15iRiQ NO. PROCESSED BY ,
tho permH fs for ona hundrod dollars(SI00)or lost.) qIR HANDLING UNIT,CFM
I certify that in tha performonce of the work for which�his , �0
permit is issved,I shall not employ ony penon in any manner gOitER,BTU
� so as fo become su6jeU to ihe Workers'Compensation lows. �r,�! avvaovnis DA7E INS�ECiDR'S SIGNAiURE -
�OMPRESSOR,BTU w lO L�/ ROUGH Z�G�L
Date Applicant .
Nnr�E TO APPIICANT: If,-after moking�his Certiilcate of VENTiIATiON SYSTEht FINAL ��S� � ti
F tian, you should become s�bject to the Workers'
C... ensa�ion provisions of Ihe Labor Code,you must for�h• EVArokAT�vE COOIEQ � VALIDATION
�with comply wi�h such.provisions or this permil shall be �
deemed�evoked � � FURNACE: �FAU VI Y 10 �
� LICENSED CONTRACTORS DECIARATION . FtOOR BTU l -.
I hereby offlrm that I om licensed under provisions of Chap�er 9 SUSPFNDED � UNIT_
'(tommencing wi�h Settion 7000)of Division 3 of the Business HEATER: WA��
and Professions Code,and my license is in full forta ond effetl. . �� � �'
3 � �' � '� � a'
License Nvmber 448349 t�c.eioss r�n � �
� v
Contracror Inland Ht�ooie 8/13 � �
❑ O
I am exempt under Sec. W
Plan check fee a
N
8.8P.C.for this reason' PERMIT ISSUING FEE S � �
Date:
Sgnarore TOTAL FEE
OWNER-BUILDER DECLARATION PIAN CHEIX APPLI�P.NT �
I hereby otfirm�hat I am eaempt from ihe Controdor's License � � .
�Law for�ha(oliowing reoson(Sec�ion 7031.5,Business and NnrnE � �� 2� � A
� Pf^rofessions Code): . �
I \I, os owner of the properiy, or my employees wilh A�oRE55 ri.���. .8
�4;.;..ye�...rtie�.<..Ie.,...��e�e„��nn.wiil do fhe wor4 ond
- ihe siructure is not intended or oifered for sale(SeUion CitV TEL NO. � ^ �5 3.2 5
70E4,Business ond Professions Code). . � ��� �
❑ I,os owner oi Ihe properry,am exclusively conlracling� OWNER Bramalea California, I11C. •�s J J.2 Jr c=i
wi�h licensed mntroctors to construct the project(Sec- �''u'�� � "
� � tion 70d4,Business and Profezsions Code). ADDRESS 3151 Airwa Avenue Suite N o 8 2 5�8 6
CONSTRUCTION LENDING AGENCY air� "- � � � rEt:NO.- �--� �- �-�-���-� - �
I hereby ofFirm�ho1 ihe�e is a tonstruction lending agenty for ,
�he performonce of the work(or which ihis permir is issued �ONTRACTOR Inland�Heatin -, IriC. - -� �
(Sec 3097,Civ.C.J. ' � .
� � ADDRE55 1696 Commerce Street � - -- � �� � '� � � - -
lender's Name
- ' CITY Corona TEI.NO. .. _ _ _. , . . .. . _
Lender's Address — ' -
SiATE LIC.
I cerlify Ihal I have read�his application ond state ihat the � LKENSE NO. - CLASS- - _. -.__. . . . . .
above info malion is mrrect.I agree�o comply with all County
ordinan e d State laws relating lo building construction,- � -
and e e o� rize representotives of this Co nty io emer � � � �- � -- -- � - - �� - �� �`
opo 11 e ov. e 'oned property for inzpef on�wposes. SEE REVERSE FOR EXPLANA70RY LANGUAGE .
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