HomeMy WebLinkAbout1195A � WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PERMIT �
I hereby affirm Ihaf I hove a cerfificate af consenl lo self ' . � I(�
insure,ora cerrificaie of Workers'Compensation�nsu�anca, "HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec.3800,Lab.C.) 76A36eC -
, CE-B18(REV.10/81�- - - �
�cy NoBWC604000Company H9_gh7 anAs l 1'�� . COUNTY OF LOS ANGELES 6UILDING AND$AFETY
Gertified copy is hereby furnished.� l
� � Cerlified�copy is filed with Ihe caunty building�nspec- � fOR APPLICANT TO FILL IN Bl11LDING ^ •�
lion de artment. � ADDRESS ' �
P � (PRINT OR TYPE ONLY)
LOCAUTY
Da�e H 13 Applicant Tn 1 anrl FIt,�„ NO. TYPE OF APPLIANCE OR EOUIPMENT FEE
� CERTIFICATE OF EXEMPTION FROM WORKERS' � NEAREST
' COMPENSATION INSl1RANCE CROSS ST.
(This settlon nead nof 6o complofod if tho work involvod by aB50RPTION UNIT,BTU DISIRi�I NO. FROCESSED BY
the perm(f is(or one hundred dollors(5100)or less.) � _
I tertify fhal in iha periormon[e oF 1he work for which fhls AIR HANDLING UNIT,CfM 1 O -
1
_ permit is issued,I shall nol emplay any person in any monner gpILER,BTU � —
so as to become subject to the Workers'Compensation Laws. �. / avvxOVAls DATE iMSGECTOR'S SIGNATURE
Dafe Applicant GOMPRFSSOR,BTU l�J ROUGH �(o-L
N�'T� E TO APPLICANT: li, after making this Certificate of VENTILATIONSVSTEM FINAL �(y�7
F tion, you should become subject to �he Workers'
C�.., ensation provisions of the lobor Code,yoo musl forfh- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or ihis permit shall be
deemed revoked. � � ' I FURNACE: FAU- V v . � , .
IICENSED CONTRACTORS DECIARATtON fiooR BTU �
I hereby a(iirm Ihat I om Itcensed under provisions of Chapter9 HEATER: SUSPENDED UNR_
'(commenting with SeUion 7000)of Divizion 3 of the Business ' wAu
ond Professions Code,ond my license is in full force and effecl. y-
� � 0
lccense Num6er 448349 lic.Class C-20 , V
z
Conhodor Tnlanri HtS_ Date R�13 � � �
❑ I am exemp�onder$et. � � ... . . _.. . v
Plan check fee a
B.BP.C.for�his reason� . y
PERMIT ISSUING FEE S � �
Date:
TOTAL FEE
- signorure . . . --
. � OWNER-BUILDER DEGLARATION . P�AN CHECK APPLICAN7 � _� � 9.Jr A
I hr.reby aifirm�hat I am ecempt(rom the Contmctor's License D . � �
Law for the following reoson(Section 7031.5,Bosiness and NAME� - . u° �� �'a
Professions Code): ' _
�l I, as owner of the property, or my emplayeez with ADDRESS - �^ •4 9 7 5
_/woges as their sole mmpensalion,wiil do Ihe work and CITY TEI.NO. •.d a
the struc�ure is nol in�ended or oifered for sole(Section 4 9,7 5 c=i
704E,Business and Professions Code). pWNER
Bramalea California, Inc. T)S.2 5�8 6
❑ I,os owner oi Ihe property,am exclusively conlracling � � �
with licensed controdors 10 construcf the projed(Seo DDRE55 3151. A.ixway Avenue, Suite R �
- tion 70dE,B�siness and Professions Code).
CONSTRUCTION LENDING AGENCY ��TY COStr1 M0S.1 -TEL.NO.- " ""- -
I hereby affirm thal there is a tons�ruc�ion lending agency for � ,
the perfarmance of ihe work for which this permlt is Bsued CONTRACTOR " �" � � �" -
(Sec.3097,Civ.C.). . . . . . .... ... .
nooRess 1696 Commerce Street — - -
Lender's Name .
Lender's Address °tt Corona � TE�."o. 734-4540 - -� - - � -
STATE LIC. -
.I tertify ihol I hove�ead ihis opplica�ion ond slale Ihol Ihe tICENSE NO. �F�183�{9 - - CLA55----C-20� - - � �
above inlormation is mrrect.I ogree fo comply wi�h all Counry � �
ordinonces nd Stale lows reloting fo building consiruction, _ ,. ._ __
and b �ihorize representatives of this Cou ty to enter .
upon ove-mentioned properiy ior insp i n orposes. SEE REVERSE FOR EXPLANATORY LANGUAGE.
tr�- � 1�, _
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