HomeMy WebLinkAbout1203A WORKERS'COMPENSATION DECLARATION �� � �
I hereby aifMm thaf I have o Certificale of consenl to self APPLICATION �FOR PERMIT
insure,or a certifica�a of Workers'Compensalion i�5��a��e, 76A364c " . � � �� � � � HEATING =�VENTILATING - AIR CONDITIONING �
or a certified capy thereof(Sec.3800,lob.C.) �E-BIB(REV,IOi81) '�' - -� � � . � -� -��--
acyNaBWC604000Compony Highlands .
Cer�ified copy is hereby furnished. �( COUNTY OF LOS ANGELES BUILDING AND$AFETY
�, Ceriified copy is filed wiih the coomy 6uilding inspeo- FOR APPLICANT TO FILL IN eunoiNG
lion deportment. (FRINT OR TYPE ONIY) ADDRESS
Da�e R�I 3 'Applicont Tnl anrl HYg_ NO. TYPE OF APPLIANGE OR EQVIPMEN7 PEE `�LITr �"" �
CERTIFICATE OF EXEMPTION FROM WORKERS' NEnREST �j
COMPENSATION INSURANCE � CRO55 ST. ' �
� (Thls secltan nasd neT 6�complated if tha work tnrolved 6y ABSORPTION UNIT,BTU D15fRi�7 NO. PROCESSED BY
fha pormff is Ior ona hvndred dollars(5100)or less.) �
1 tertify iha�in Ihe performance of the work for which�his A�R HAN�LING UNIT,CFM � . O
permil is iss�ed,I shall not emp�oy any person in pny manner
- sa as to hecome subjec��o the Workers'Compeniolion Laws. 801LER,BTII APGROVALS DATF INSPFCfOR'S SIGNATURE
Date ePP�i�o�� COMPRESSOR,BTU ROUGH � '.(�i�� �
N(�TICE TO APPLICANT: li, afler moking �his Ceriificafe of VENTILATION SYSTEM FINAL T„to
� f Yiion, yau should become subject to �he Workers' -
C.._pensation provisions of Ihe Lo6or Code,yov most forfh- EVAPORA7IVFCOOLER VALIDATION �
wiih comply wilh such provisions or �his permit sholl be .
deemed�evoked. � � � FURNACE: FAU- IT � - O � . �
LICENSED CONTRACTORS DECLARATION � FLOOR BTU �
I hereby oifirm thol I om licensed under provisions of Chopter 9 SUSPEN�ED UNIT_ �
�(commencing with Secfion 7000)of Division 3 oF the Business HEATER: Wa��
, and Vrofessians Code,and my license is in iull force and effecL !� --
a
L�cense Number 44H349 tic,Closs C-20 , d
V
!f:
Contracro� Inland HtQ. Dme $�13 . p
F
� V
I am exempt under Sec. W
' Plan check fee
B.BP.C.for Ihis reason' � � � m
- PERMIT ISSUING FEE S ?
Dafe:
S�qnotore TOTAL fEE
OWNER-BUILDER DECLARATION PLAN CHECK AFPUCANT '
I hereby affirm rhal I am exempt from Ihe Conrraclor's License D �
Law for tha following reason(SeUion 7031.5, 6usiness and NAMe ' -
Prrofessions Code): - - � :� 2 Q�A
I ll, as owner of�he property, or my employees with /+DDeE55 � . � � - -
�wages ci th?ir sole cempenseticn,will do th=werk end �� � � � ��
ihe structu�e is no1 intended or offered for sale(Section C�?Y . TEt.NO. � �
7044,Business and Pra(essions Code). . ��• �4 9 7 5
OWNER gramalea California, Inc.
❑ I,os owner of Ihe proper�y,om eatlusively conlrocting - . �a��4 g,'7 5�
with licensed contractors to construU the project�Seo- - �"�a�� �� ---
� lion 7044,Business and Professions Code). ADDRE55 3151 Airway Avenue, Suite N �s 2 5�8 6
� CONSTRUCTION LENDING AGENCY � -- -- ���� - . �
I hereby affirm Ihat ihere is a construction lending agency for Clrv Cos ta�Mesa TEL NO. .
Ihe performance of the work for which ihis permil is issued - �pNTRACTOR� - � � ►
(Sec.3097.Civ.C.). . . _. . .. � . .
. . __... . .._ _
ao�aess 1696 Commerce 5treet -- �
lender's Nome - -'
aTr Corona Tei.No. 734-45k0 _
Lender's Address � � �� � -� -
I certif �ha�I hove read�his a lication and staie�hat�he STnTE LiC. �
Y PP LICENSE NO CLA55 - _ ... __ _.
above inform tion is corcect.I ogree lo minply wilh all County � � � - � �
ordinances n State laws relating l0 6uilding c nstruttion, . � � .
and h b a thorize represenratives of this Co�ty to enrer - � � � - � �� - - � -- �: ��
opon o e ntioned property far ins�t�� urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE_. _
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