HomeMy WebLinkAbout1209A WORKERS•�oMPENSAT�oNOE��ARAT�oN � qpp��CATION FOR PERMIT �
I here6y ai(irm Ihal I have a cer�ificale of consenl 10 self . +
insu�e,or a cer��fitme of Workeri Compensarion Insvrante, HEATING - VENTILATING - AIR CONDITIONING j
or a certified copy rhereof(Sec.3800,La6.C.) . 76A36aC .
�CE-818(REV.10/81 J .. . . . - ... . . .
Policy No.BWC6O4OOOCompany H3ghlattds � � �
� Certiiied topy Is hereby furnished. 1 � COUNTY OF LOS ANGELES . ' BUILDING AND SAFETY
� Certified copy is filed with the county building inspet- • FOR APPLICANT TO FILL IN Bu��DiNG '
tion deporlment. AODRE55
8/13 Inland HtQ. (PRINTORTYPEONLY) `�`ITM
Dote Applicont NO. TYPE OF APPLIANCE OR FOUIPMENT FEE � �
� CERTIFICATE OF EXEMPTION FROM WORKERS' NEazESi
� - COMPENSATION INSURANCE ceOsssi.
(This��etlon n�ad not ba eompl�t�d Ii�he werk Invelvod by ABSORPTION UNIT,BTU o61RiCi no. P4 esseo er
1ho pormN fs for one hundred dolla�s(5100)o�lets.) �
I cerfify thol in fhe periormonce of fhe work ior which fhis P.IR HANDLING UNIT,CFM � I O
permi�is issued,I sholl nat employ ony person in any manner BOiIER,BTU
— , so as lo become subjeU to Ihe Workeri Compensotion Laws. nvvapvnis DatE MSPECfOR'S S�GNAfURE —
Dafe opplicanf COMPRESSOR,B7U O OV ROUGH _� _
Nr`�CE TO APPIICANT: If, afler moking this Certificate of VENTILATION SYSTEM FINAL . � _£�
( �ion, you shou�d become subject to the Workers'
C...., ensalion provisions of ihe Labor Code,you must forth- EVqppRATIVE COOIER VALIDATION
with comply wiih such provisions or tliis permil shall be �
deemed revoked. � � FURNACE: FAU V � � Q /yt , _ , �
LICENSED CONTRACTORS OECLARATION � FIOOR BTU 1..�� -
I hereby afti�m that I om licensed vnder provisions of Chopler 9 HEATER: SUSPENDEO UNiT—
�(commenting wi�h Settion 7000)of Division 3 oi the Business ' WA« �
and Professions Code,'and my license Is(n full forte and eifect. I � � }
a
License Number 448349 �i�,Class L''20 � V
�
Coniroclor Tnl an�j��, Do1e $.��1i �
❑ I om eaempt under Sec. . . _ _ . . . w
Plan check fee o-
N
8.8P.C.for this reason' PERMIT ISSUING FEE$ Q z
Dale:
Sgnatore TOTAL FEE
� OWNER-BUIIDER DECLARATION PLAN CHECK APPIICANT ,
I here6y aifirm thot I om exemp�from the CoNractor's License � � n,� 2 Q C�A
Law for the following�eoson(Section 7031.5,Business and NAME `
P1—rofessions Code): - �.� � � � �
! �I, os owner of the property,or my employees with AD�RESS � � 8
weges as th=ir eole compensa�ion,will do thn wo�k nnd � �•5 3.2 5
the structure is not intended or oifered for sale(Section � CITY � 7Et.NO.
7044,Business and Professions Code). � - - d* s�3,�,rj�
owrvea gramalea California, Inc.
- ❑ I,ax owner of Ihe p�oper�y,am e.dosively con�rocring . Man . .. .. .. O B 2 5"a 6
with licensed tonfroctors lo mmtruU the projeU(Seo- ADDRE55 3151 Airwa Avenue Suite N
tion 7044,Business and Professions Code).
CONSTRUCTION IENDING AGENCY niv COStH Pfesa � rei.No. �� � � � �
I hereby offirm Ihat�here is a conslroclion lending agency for ► . .
the performonce of the work for which this permit is issoed CONTRnCTOR Inland Heating,- Ine.� � � -
(Sec.3097,Civ.C.). - . . . .- . . .. . . .
� - ADORESS 1696 Commerce Street � � � � � � - - ' �
Lendei s Nome
arv rei.No. . —4540
Lender's Address �
I cerlify that I have reod ihis opplitalion and staie�hat ihe- ICENSE N0448349 .... CtCn55. .C-20
.. _ _. ... .._. __. . __ ..
abo�e iniormation is correct.I ogrea lo comply wilh all Caunty � �� ���
ordinances nd State lows rela�ing to 6uilding construction, ' , , � '
and er u� ri:e�epresentatives of rhis Co nry ro enier - � .��� - � ��- -` - ������� � �
opo t , b v - entiO�ed p�operty for insp i n orposes. SEE REVERSE FOR EXPLANATORY LANCUAGE
Signmure of Appl�mnt or Agent Do+e- . . ......... ... ... . .. . .. .
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