HomeMy WebLinkAbout1210A WORKERS'COMPENSATIONDECLARATION � APPLICATION FOR PERMIT �
I hereby oifkm that I have a certificate of consent to self � �
insure,or a certifitaie of Worke�s'Compensation��:�,00ce, �aa�a<c HEATING - VENTILATING - AIR CONDITIONING
or a certified topy�hereof(Sec.3800,lab.C.) CE�-B�e(REV.l0iet) � � �- - -- � ��� �
, Policy No. BWC6O4OO�Jompany HIGHLANDS � � � �
❑ Certified mpy is hereby furnished. 1��J, COUNTY OF LOS ANGELES BUILDING AND$AFETY
� Certi(ied mpy is filed wi�h rhe tounty baild�ng inspeo- FOR APPLICANT TO FILL IN � BuuowG
tion deparlmenl. �PRINT OR TVPE ONLY� A�DRESS
oa�a $�13 APP���a�� Inland Htg. iocnun � �- /�a �
NO. NPE OF APPLIANCE OR EQUIPMENT. FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' � NEneEST �
� COMPENSATION INSURANfE � CROSS ST.�
(Tht�saciton nead nol ba compl�tad 1F Tha work involved by ABSORPTION UNIT,BTU OISLRICT NO. GRp�[SSED BY�
fho permil ls for one hvndred dollars(f100�or less.) AIR HANDLING UNIT,CFM I O
I cerlify thot in Ihe performonce of Ihe work for which ihis-
permi�is issued,I shall not employ any person in any manner BOILER,BTU
— so as to become subject lo Ihe Workers'Compensation Lows. aPcaovnis onr[ INSCFCTOR'$S�GN4TUPE —
Do1a APPIicaN � GOMPRESSOR,BTU ROUGH �-i7,�
Nr'TICE TO APPIICANT: If, af�er making ihis Certificde o( VENiILATIDN SYSTEM � � FINAL � ��� (�j��},(rJ .
f tian, you should become s�bject 10 the Workers'
C....�ensation provisions of Ihe labor Code,yoo most forth- EVnPOanTIVE CoolEa VALIDATION
wilh comply with svch provisions or fhis permit shali be � .
-deemed re�oked. � �� FURNA�B FAU G VI Y h ,
� LICENSED CONTRACTORS DECLARATION � FtOOR BTU . O OV .
'I hereby offirm thal l om Ilcensed under provisions of Chapter9 HEATER:' - SUSPENOED UNiT_ ' , ,
�(commencing wi�h Secfion 700D)of Division 3 of ihe Business ' Wa« �
ond Professions Code,and m license is in full force and eifect. ' � �
License Number 448349 ���,�lass C-20 I � , U
m
Contrector Tn1anA H1-g_ Dare R�13 � � �
❑ . . . _ . _ � � �
I om ezempt under Sec. �+
PI6n check fee a
8.8P.C.for this reason' � - �
PERMIT ISSUING FEE S Z
Date:
TOTAL FEE
' Signature
� OWNER-BUIIDER DECLARATION PIAN CHECK n7auCANT . � �
I hereby aifirm iha�I am exempt from the Contractor's License , � � � �
Low for the following reason(Section 7031.5,9�siness ond NaME
PI—rofessions Code): . � :�� 2�•�A
1 �I, as owner of the properfy, or my employees with ADORE55 ��♦.e s •8
.,�wages as their scle cempens�!�on,�vill da th�werk and
• the structure is not iMended or offered for sale(Section CITY � 7EL NO. . .
7044,8usiness and Professions Code). - �� � � � . ' ��' ���2 b
OWNER gramalea California lnc.
❑ I,as owner of the property,am e.clusively con�rac�ing ' d e a 5 3.�5�
- with I�censed contracrors to cons}ruct the project(Sec- 'wAiL -- - - � �� , �
� � lion 7044,Business and Professions Code�. ?.DDRE55 � 1 0�8 2 5=8 6 �
CONSTRUCTION LENDING AGENCY CiTY� - �COSC3�M2SH '� ' TFc NO:� ���' ��-'- � ---
I hereby affirm that there is a construUion lending agency for , .
the performonce oi the work for which this pe�mit is issued CONTRACTOR Inland Heating� IriC. - �
(Set.3097.Civ.C.). . .
ADDRE55 �16 ommerce Street � � � -- -� ��� � - � � � -
Lender's Name
. � GITY . . TEI.NO. _ _. __ . . . __ �. ._ .
lender's Address � — �
SiATE • LIC. C—ZO �
I certify that I have read this applitalion and state Ihat the LIGENSE NO. . �+�+8349 . CLA55 -. . . . ..
above informalion is corrett.I agree�o comply wilh all County �
ordinances a Stote lows�elating to building onelrucrion, � , ,
and here y thorize representatives of�his C oMy to enfer � � � � � ���� � � �� � �� � ��� � � - ' �
�pon th I v m n ioned property for ins ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agenl a�e . . . .. .. ... .... .. . . .. _�. ' .
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