HomeMy WebLinkAbout1193A WORKERr�oMPENSAT�oNOE«ARAT�oN . � . �. . APPLICATION FOR PERMIT �
I hereby offi+m that I have a certifica�e of c'onsent to self `_
insura,or o ceriificate oi Workers'Compensarion Insurance, - ` HEATING - VENTILATING - AIR CONDITIONING ��
or a certified mpy thereof(Sec.3800,Lab.C.) ��'�°� � ,, . , . . ,.__,
Pol�cy No�WC604000Compo�y Highlands CE-818(2EV.10/8ry
� Certified copy is hereby furnished. � � 11�' COUNTY OF LOS ANGELES . � BUILDING AND$AFETY
� Certified copy is filed wirh+he co�nry building inspeo FOR APPLICANT TO fILL IN BUILDING O(�1
ADDRESS �SL I
�iOn dBpaflmen�. � (PRIM OR TVPE ONLY)
Dofe $�13 nPP�;�a��Inland Htg. � �aAun'
NO. TYPE OF APPLIANCE OR E�UIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NE/+eEST �
COMPENSATION INSURANCE � CROSS ST. � .
(This secflon need not be tomplsTed if 1he work lnvolved by ABSORP710N IJNIT,BTU oisraici No. veocEsseo er
the permit is lor one hundrad dollars(f100)or leca.) . �
I certify that in 1he performante of the work for which this AIR HANDUNG UNIT,CFM� I O
l
permit is issued,I sholl no�employ any person in any manner gpi�ER,BTU —
so as to become subjec�to the Workers'Compensation Laws. � APPaOVnls DAiE INSGECTOR'S SIGNATURE
Date �� Applitant 1 COMPRESSOR,BTU Q� ROUGH Z-(�(j� ((��it—
N�'T�CE TO APPLICANT: If, oifer moking fhis Cerlificaie af VENTILATION SYSTEM FINAL �.y ����
E �tion, you should become subject to the Workers'.
C�.... ensation provisians of the La6or Code,you must forih- EVnvORATIVE COOIER VALIDATION .
��with comply with such provisions or �his permit shall be -
deemed�revoked. . - . FVRNACE: fAU VI -
LICENSED CONTRACTORS OECIARATION � RooR eTU O G�
- i hereby a(firm ihat I om licensed�nder provisions of Chopter 9 HEaTER: SUSPENDED UNIT_
�'(commencing with Section 7000)of Division 3 of the Business ` wA0.
and Profeuions Code,ond my license is in full forte ond effect. �' � p},
� � O
Licensa Number 448'�49 i��.eio5s �-�� - � . . �
m
Conrroctor Inland Htg. Oate 8�13 �
�
❑ I am exempt vnder Sea . . .. . �
Plan check fee W
a
B.BP.C.for�his reason� . - �
PERMIT ISSUING FEE S , —
Date:
TOTAL FEE
Signarure ' _ � .
OWNER-BUILDER DECIARATION aaru CHECK AP�icnNT � �
I heieby aifirm�hot I am exempt from the Contractor's license . � ' .
Law for the following reason(Settion 7031.5,Business and NAME � . . ' �� � 9,3 R
P�ro^fessions Code): _ . .
I l�, os owner of Ihe property, or my employees wifh ADORES$ �,��y ♦ y S .
� .�wages as the�r sole compensotion,will do the work and qtt TEI.NO.
the structure is no�intended or offered for sale(Section � "� •4 9,7 5
� 7044,Bosiness ond Professions CodeJ. OWNER •
Bramalea California, Icn. x
� ❑ I,os owne�of�he proper�y,om exclusively conhacling s�A 4 9,7 5 c�
with licensed controctors�o consiruct�he projecl�Seo- �"�A�L --� -
� tion 7044,Business and Professlons Code). ADORE55 3151 Ai.xwa Avenue, Suite N� 0 8.2 5`"8 6
CONSTRUCTION LENDING AGENCY ciTv � � �tet.No. � -�-- �
I herebyoffirm that the�e is a construttion lending agency for Costa Mesa ,
Ihe performance o(ihe work for which Ihis permif is issued CONTaACTOR '
�sec.3os�,a�.c.). Inland�Heati
� - ADDRESS 1696� Co�nerce Street � � �-- � - �- - - � � - �- �-
Lender's Name � .
aTv Corona - TEi."o. 734-4540 -
Lender's Address �
STATE LIC. - , �
I certify thot I have reod this opplicalion and state Iha�the ucen,se r,o.448349 � anss � C-20 . _ . ._. .. _.._. . . . .. _ .
above infor lion is correct.I agree to comply wiih oll County �
ordino ces d S�ate laws relating to building ons�ruction, . _ .. _, . , _ ,.
and h e uth ,Ize rep�esen�atives ot�his Co My to enter . �
opon + b � niioned prope�y tor inspxt o pu�poses. SEE REVERSE FOR EXPLANATORY LANGUAGE
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