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HomeMy WebLinkAbout1216A �WORKERS'COMPENSATION DEGLARATION � �Z r.G, � [hereby aff'rrm thot I have o cer�iFimte of�a�5e��fo;e�f . � . APPLICATION FOR PERMIT insure,or a ce�1i(icde o(Workers'Compensation�nsurance, �bA3a�c HEATING - VENTILATING - AIR CONDITIONING or o certi/ied copy thereof(Sec.3800,lab.C.) � �E-Bte(REV.�o/Bt)� � � -- � -� O�y No. BWC6040QQ,„Pa„y_Hi�hlands ' Certified topy is hereby furnished. `��� COUN7Y OF!OS ANGELES BUILDING AND SAFETY �, Certified copy is fileJ witb�he counry bo�lding inspeo- FOR APPLICANT 70 FIIL IN BUIIDING � lian deporfine�t . (PRINT OR TYPE ONLY) ADORE55 Da+e S/13 nppl�eont Tn1�.,,� ut„ io�acm �(��.- L+ NO. TYPE OP A7PLIANfE OR EQU�PMENT iFE CER7IFICATE OF EXEM7TION FROM WORKERS' .. NeaaEST �� � COMPENSATION INSURANCE � � Cap5S5T. (ihH settlon naad no}6o tompld�d li the work involvsd by ABSpRPTIDN UNIT,BTU Di9vIC�NO. PROCESSED BY �ho parmlt fs for ona hundred do�lors(5100)or le��.) I� � AIR HANDLING UNIT,CFM � I certify that in the periormonce of the work for which thiz � _ permit is Issoed.�I sholl no1 employ ony person in ony manner BOIIER,BTU so os to become subjecf fo the Workers'Campensalion Lows. nv000v�is DATE INSPECTOR'S SIGNAiURE 8/13 Inland ht � COMPRE$$OR,BTU ��� (S � ROVGH �y�7 ��� Dote APPlicom �'•� � - P""CE TO APPLICANT: If, af�er moking this Cerlificafe of VENTIlAT10NSY5TFM FINAL 3��� �� I �tion, you should bemme subject to the Workers' . ���C���pensa�ion provisions of Iha labor Gode,you musf lorth- EVqppgATIVE COOLER VALIDATION with comply wNh such provisions or this permit shall be deemed revoked. " � - FURNACE: FAU�_G I QO . LICENSED CONTRACTORS�ECIARATION � ftOOR BTU !hereby offirm thaf I am 6censed onder provisions ol Chopter 9 HEATER: SUSVFNDED UNIT_ �'(commencing wiih Sectian 7000)of Division 3 of the Businesz WAu and Proiessions Code,and my I�cense is in full force ond effect. � 1 „ � �� ��� >- .L(� d License Nvmber 448340 Lic Class r.—�n- ► . � o � V Commctor Itt18nd Htg. Dme 8�13 °r O ❑ ~ I am eMempt�nder Sec. � W Plan check fee Q. 8.8P.C.for this reoson� y Dole: PERMIT ISSUING FEE S ? Signarore TOTAL FEE - OWNER�BUILDERDECIARATION RANCHECKAPPLICANi I hereby oifirm that I am exempt from�he Contractor's Litense , law for the following reoson{Sec�ion 7031.5, Bvsiness ond NnME � :'•� G i,b A Professions Code): � � � � ' r�I, 05 owner of ihe property, or my employees with ADDRF55 ��,� � +e 8 --- woges os fheir sola mmpensalion,will do the work and ihe sir�cfure is not in�ended or oflered for sote(SeUion CiN rEt.NO. � � �5 a 2 5 7044,Busine:s and Professions Code). � OWNER Bram:ilea California, Inc. � • •5 a 2 5� ❑ I,os owner of Ihe property,om extlu5ively coniracting �` � wi�h licensed mnfroclors�o[onstruct the�projetf($ec- qDDRE55 �646-6e�eme�ee-6Er-eeE 3151 Airwa Avenue 0&2 5-S 6 rion 7D44,Business and Pro(essions Code). ' CONSTRLlCTION LENDING AGENCY � CIN COStd TiHSfl - T[l,N0. � -- ' I hereby olfirm fhol Ihere is a conslruction Iending ogenty for , the performance of the work(or which�his permif is issued coNrancroa Inland Heatin � Ine. � � (Sec.3097,Civ.C.). . gs ' . . .. . . lender'sName ADDRE55� 169( COIMI0iC0 Street - � - � �-�� � � � � . Lender's Address - - ��TY� CoTOriH T��NO� 734-4540 � � �� � � �- . - . .. I terlify ihot I have read Ifiis vpplicofion and stale Ihal tfie icen;se No. 448349 QA55 C'-20 above informa�ion is correct.I agree to comply wiih oll Coonry � � � -- �� � ' ordinancespp d Slo�e lows relating b buildi g construuion, . and F� reb(dut `ize representafives of Ihis ounty to enter � � � .� - � - - � � �-� - upon�h 66 mhntioned prvperty for i�sp cnon purposes. SEE REVERSE POR EXPLANATORY lANGUAGE v Signo�u.e of Applironf or Age�f �o�a , � . . 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