HomeMy WebLinkAbout1217A WORKERS'COMPENSATION DEQARATION � • � . Z� �
I hereby affirm ihat I have a certificote o(consent to self APPLICATION FOR PERMIT �
��s�.e,or a ce.flficate oi Workers'Compensalion Insorance, ,�,36ac . HEATING - VENTILATING - AIR CONDITIONING
or a cerui�ed copy�hereof(Sec.�3800,Lab.C.)
BWC60400@ Hi hlands �-8�8(REV.10/81) -
P❑ol'icy No. ompany b' COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished. 1`�I�
� Certi(ied topy is filed wiih the covnty 6uilding inspeo- FOR APPLICANT TO FILL IN eunoiNG 1.1 �
tion deparlmenl. ADDRE55 i l
8/13 Inland Htg. (PRINTORTYPEONLY) `�"Tv
Dote Applicanl -f G $ ' .
. NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST � .
COMPENSATION INSURANCE CkOSS ST. - .
(Thf�satllon nesd no}be compl�fad if ffi�work Involv�d 6y ABSORMION UNIT,BTU � ois�aicr No. vxocesseo er
}he parmk is for ono hundrad dollars(SI00)or less.) ��
I cerfify that in ihe performance af 1he work fOr whiCll Ihis �+�R HAN�IING UNIT,CFM (O '
� permit is issued,I shall not employ any person in any manner �
- so as to betome subject to fhe Workers'Compensotion Laws. BOILER,BTU APCROYAlS DAIE INSVECiOR'SSIGNATURE
Date Appli[ant COMPRESSOR,BTU lO LV ROUGH ��S �!�
NnTCE�TO APPLICANT: If, after making lhis Cerliiicale of VENTRATIONSYSTEM FINAI Z�y) �
f tion, you sho�ld become subject fo �he Workers'
-C. . ensar�on provis�ons of the lobor Code,you must forth- EVAPORATIVE COOLER VALIDATION �
" with compiy with svch provisions or this permit shail be
deemedrevoked. FURNACE: FAU VI IQ
LICENSED CONTRACTORS DECLARATION FLOOR BTU �
I hereby affirm that I am Ilcensed under provisions of Chop�er 9 HEATER: SUSPENDED UNIT_
�(commencing with Section 7000)of Division 3 of the Business � WAIL
and Rofessions Code,ond my license is in full force ond eflecl. ' ?'
I � a
ticense Nvmber 448349 lic.CIasS C-20 � � - , V
Comroctor Ittl and Htg. Dote 8�13 a
O
� ❑ I am exempt under Sec. . . . . � - w
Plan check fee N
B.BP.G for ihis reason' pERM1T ISSUING FEE$ �Q _ 2
Date:
Sgnature TOTAL FEE
OWNER-BUILDER DECIARATION � PLaN CHECK av7liCANT � ' ' �
I hereby affirm ihat I am exempt from the Contractor's License _ _ D
law for Ihe following reoson(SeUion 7031.5, Bosiness and NAME _ �
P�'ro^fessions Code): � - s� 2�,7 A
I �I, os owner o1 the property, or my employees with AOORESS
�_1 wages as thcir solc compenso�ion,will do the werk end �:•e e • e a
the structure is not intended or offered for sole(Section CITY TEL NO.
7044,Business ond Pro(essions Code). � � o e�3,��
� OWNER gramalea California lnc.
❑ I,os owner of�he property,am e.tlusivel contrac�in �
with licensed conhacfars lo consfrocl the projecl�Sec9- DDRESS .3151 A�.�ay AV0RU0� Suite N � � '° °5�2 5`
� fion�7044,Business and Pro�eSsions Code).
CONSTRUCTION IENDING AGENCY - � CIN COSta Mesa Te�.No: �� � 0 f3 2 5—8 6
I hereby offirm ihot�here is o conshuction lending agency for �
the performonce of the work for which this permit is iss�ed CONTRAttOR Inland Heating,�Ine. ,
(se�.sos�,c��.c.). _
nooaess 1696 Coinmerce Street
lender's Nome .
uTr Corona rei.rao. 734-4540. _
lender's Address . - ��
I cer�ify thal I have reod this opplimtion and state�hat Ihe iiceNse No. 448349 � ciAss C—ZO . . .
__ -. _ .
above infor tion is corrett.I ogree to tomply with all County . � � � � � �
� ordinances ar�d State lows rela�ing to building construction, _ .
and h e a�iho�ize representa�ives of ihis C unry to enter � � '� - � � �� � � � �- - �
upon e boL - enroned propeny for inspec ion po�poses. SEE REVERSE FOR EXPLANATORY LANGUAGE_ .
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