HomeMy WebLinkAbout1215A WORKERS'COMPENSAiIONDECLARATION . APPLICATION FOR PLRMIT �� �
I hereby a(fkm that 1 have o certificote of tonsen�to self
insu�e,or a certificare oi Workers'Compensaron Insuronce, ��3�� HEATING - VENTILATING - AIR CONDITIONING
or a cer�ified copy thereof(Sec.3800,lob.C.) �_eie�ReV.t0iet) � � - �
�cyNoRWCh,(1/�fl(1flCompony HiQhlands
Cerrif�ed copy is hereby fu�nished. ���` COUNTY OF LOS ANGELES BUILDING AND$AFETY
� Cernfied copy is filed wi�h the county building�nspeo- FOR APPLIGANT TO FILL IN euuoiNG 4]d�
ffon deporlmenl. � (PRINT OR NPE ONLV) NDDRESS ���f
pare 8/13 naal�conr Inland Htg. iocnurr �r '�
NO. TVPE OF APPLIANCE OR FQUIPMENT � FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEnkESi � 1
� COMPENSATION INSURANCE . CRO55 5T.
(Thle t�clion naod�ot bo tompleted ii tha work involv�d by ABSORPiION UNiT,BTU Di51RK1 NO. V OCESSEO BY
fhe parmlt Is(or one hundred dollars(5100)or bst.) ,
1 cerlify 7hot in the performonce of the work foi which this AIR HANDtING UNIT,CFM
permil is issued,I shall nal emplay any person in any monner BOILER,BTU �
so as to betome subject lo the Workeri Compensation Lows. . � nvvuovnis �ah INSGECiOk'S SIGNAi11RE
Dote � APPlicont I COMPRESSOR,BTU (� � ROUGH �L�,e—�
P'^'+CE TO APPLICANT: If, ofter meking this Certifica�e Of VENTIIATION5Y5TEM iINAL 3�3p.� ..����
- ( �tion, you should bemme subjed lo the Workers'
�- C����pensation provisions of Ihe Labor Code,yov most forlh- EVqPORATivE�OOLER � VALIDATION
wl�h comply with suth provisions or lhis permif shall be
deemed revoked. � 1 FURNACF. FAU� VIT
- LICENSED CONTRACTORS DECLARATION- t fLOOR BTU (O �
I hereby aRirm thot�am licensed under provisions of Chapler 9 SUSPENDED UNiT_
'�commencing with Section 7000)of Division 3 of ihe Business HEA7ER: WA��
and Professions Code,and my Ilcense is in full force and ef(ecL� � �n' y
Li�ense Number 448349 lia Closs C-20� , Wr � ► t,�,r
ae
Controctor In1anA Htg_ Date R�13 �
❑ V
I om eaemp�under Sec. �++
Plan check fee °�
w
8.8P.C.for this reason PERMIT 1SSUING FEE S �Q � z
�a�e:
Sgno�ore TOTAL FEE 53
� OWNER-BUILDER DECIARATION PLAN CHECK APPLICANT _
I hereby affirm thof I am ezempl(rom Ihe Conirottor's License .
Low for�he following reason(Secrion 7031.5,Business and NAME . . � � '� 2�,5 A
Prolfessions Code):
r 1I, ns owner of Ihe property, or my employees wilh ADDRES$ +�� � ° ° �a
� - .��woges as their sole compensotion,will do the work ond ��N TFI.NO. � ° • �J 3.�rJ �
the strucWre ii naf intended or ofFered for sale(Section �
7044,Business and Professions Code). - � -� - —
OWNER Bramalea California, Inc. . ° ° •�a[5�
❑ I,as awner of the property,om exclusively controc�ing
wi�h li�ensed contraaors ta construtl fhe p�o�eU(Seo DDRE55 3151 Airwa Avenue Suite N� C£3 2�''8 6
� �tion 7044,B�siness and Professions Code). � . �
CONSTRUCTION LENDING AGENCY � Ciiv Costa�Pfesa TEL NO. - �
I hereby aifirm that there is o construtlion lending ogency for ,
the performonce of the work ior whith this permil is issued COnlTu.4ROR Inland Heating, IRC. �
(Sec.3D97,Civ.C.J. . . ...- -' - .. . . .. . .
aooaess 1696 Cownerce Street • '
Lender's Nome
CITV Corona TEL NO. _4 O _ _ . _
Lender's Addresz �
I ce�tify that I ho�e read this applicotion and stote�har the i ceNse No. 448349 �LA55 C-20 _ _ _
above information is correct.I agiee to comply with all Counry .
ordinances ond$lale laws reloting lo buildin construction, . � �
and her y a orize represento�ives of this C unry to eNer . � � , � � � "
upon rh o -mentioned property for i �ian porposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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