HomeMy WebLinkAbout1202A WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PERMIT � 7 � � �
I hereby a(fhm that I have a cenifim�e of tonsenl ro self
insure,or a cerr�ficare ot Workers'Compensarian Insu�ance, �aa7eec HEATING - VENTILATING - AIR CONDITIONING
or o certified copy Ihereof(Sec.3800,La6.C.) � ,_ ,. _ . . �
CE-B1B(REV.10/Bi)� . .
O�y'NoBWC604000Compony Highlands �
Certified copy is hereby fornished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed with the county building inspec- FOR APPLICANT TO FIIL IN � �� BUi�o�NG �l�G/„ 'r�
. fion deparlmenl. . �PRINT OR TVPE ONLY) AD�RESS l.t,��(J V
Da�e 8�13 Applicani Inland Ht . �a"��rv
NO. TYPE OF APMIANCE OR EOUIPMEN7 FEE
-CERTIFICATE OF EXEM7TION FROM WORKERS' ' NEAREST � /„
COMPENSATION INSURANCE . . CROSS St. � (L .
(Thi�socfion need not 6e comploted i(fha work Involvad by ABSORPiiON UNIT,BiU piS1YtC1 NO. �Rp�E5SF0 BY
the perm�f ts Ior ono hundred dollon(5100)or less.) AiR HANDLING UNIT,GFM J�
I certify�ha��in Ihe performonce oi the work(or which ihis _
permit is issued,I shall nol employ any person in any manner gOiLER,BTU
— eo as lo betome subject�o the Workers'Compe�safion Laws. / nvvaovats unrt INSMCTOR'SSIGNAiURE
Date 4pplicont � COMPRESSOR,BTU W W ROUGH �
NC�TlCE TO APPLICANT: if, ofter making this Certifico7e of VENTIIATION SYSTEM FiNAL � ��
F btion, you should become su6jed to the Workers'
C._.bensolion provision5 of the Labor Code,you musf forlh- EVAPORATIVE COOLER VALIDATION
witH comply wi�h such provisions�or �his permit sholl be .
deemed revoked. � 1 FURNACE: FAU_G VI D � /Yl
. . LICENSED CONTRACTORS DECLARATION � FIOOR BTU lAJ
I hereby affirm that I om licensed vnder provisians of Chapler 9 - HEATER: SUSDENDED UNIT_
'(mmmencinq with Sec�ion 7000)of Division 3 of ihe Business w�`« . -
ond Professions Code,and m litense is in full force and effect. }
licensa Number 448349 �ic.Class C-2D I � �� � , u
�
Co�tractor Tnland Htg. Dme 8113 a
❑ I om exempf under Sec. _ . . � u
Plan check fee W
8.8P.C.for rhis reoson� a
�
PERMIT ISSUING FEE S � Z
Daie:
TOTAL FEE
Signolure �
OWNER-BUILDER DECLARATION -� ttAN CHECK ArPUCAnIi . .
� I hereby affirrri rhat 1 am exempt irom the Conrractor's License . � �
law for the following reason(Section 7031.5, Business and NAME � �
Prolessions Code):
� I, os owner of ihe property, or my employees with ADDRE55 � �� 2 Q 2 A
�wag=s as th=ir sole tempensalion,will do th�wcrk ond p7v TEL.NO. � 1•
� �he strudore is na�iniended or offered for sale(Section . h��'� • •a
7044,Business and Professions Codej. OWNER � '
Bramalea California, Inc. � „ �{y 9�5
❑ I,as owner of�he properly,om extlusively conliacting �� - .
�wiih licensed conlroctor5 b consfruct fhe project(Ser qDDRE55 3151 Airway Avenue,�� Suite N� ' s
- � �tion 7044,Business and Professions Code). � d � b 4 9,7 5�
� CONSTRUCTION LENDING AGENCY � CITY Costa Mesa � r�."o.� � � � � � �- d g,2 5�8(�
I hereby oifirm that Ihere is a conslruttion lending agency for , � �
the performonce of the work for which this permif is iss�ed [ONiRaCTOR Inland 08t1
(Set.3097,Civ.C.). . . � . - .
� - ADDRESS 1696 Commerce Street ��- � � � -� - � � . �� ' ��
Lender's Name
an Corona TE�.� 734-4540 - . -
lender's Address
STATE LIC.
1 tertify fhot I have read rhis apphcm�on a�d state that the LICENSE NCI{LFH3�i9 �CLA55 �C—ZO - � � - �-�� �
above informotion is correct.I agree to tomply wi�h all Gouny .
�ordinonce nd Sto�e Ipws rela7ing to building construction, , _ , _ , _ __. __ _ . _ _ . _ _ , . _. ,
'and re y aulhori:e represenlalives of�his unty to enle� - . - �
upo h av en�ioned property for i�rion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE . • _ _ . _ _
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