HomeMy WebLinkAbout1204A � WORKERS'COMPENSATION DECLARATION - ' ' � �V �
I here6y a(fkm ihal I have a certificate of�o�,e��,0 5e�f - . �APPLICATION �FOR PERMIT .
insu�e,or a cer�Htca�e of wo�kers'Compensation Insuronce, �bA�� HEATING - VENTILATING - AIR CONDITIONING
or a certified copy ihereof(Sec.3800,Lab.C.) . �_818�aEV.IOi81) . � ' ' �� � �� �
Po�;�y"�wC604000 Compony Hi�hlands
❑ Cer�itied copy is hereby furNshed. 1 l COUNTY OF LOS ANGELES - BUILDING AND SAFETY .
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� Certified copy is filed with the caunty building inspec- FOR APPLICANT TO FILL IN eui�oiNG �'(�7}
tion deparlment. . ADDRESS �i �U
(7RINT OR TYPE ONLV)
Dote $�13 Applicant Inland Htg. �aAun' '�
NO. TYPE OF APPLIANCE OR EOUIPMENT . � FEE
�CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST I �
COMPENSATION INSURANCE - � CROSS ST. ,
(This�actlon n�ad not bo complel�d�f fha werk involved by ABSORPTION UNIT,BTU DISiR1�I NO. PRp�E55E0 BY
tha permH fs For ono hundrad dollan(5100)o�less.) � � ' �
I certify thot in Ihe performonce of fhe work for which Ihis AIR HANDLING UNIT,CFM O
permi�is issued,I shall not employ ony person In any manner �
- so as to become subject lo the Workers'Compensalion laws. 9011ER,BTU APPROVAlS DAiE MSPECTOR'S SIGNANRE —
Dote applicont � COMPRESSOR,BTU �Z,�a� . pG ROUGH IZL�%
NnT tCE TO APPLICANT: If, afte�making this Certifica�e of VENTILATIDN SYSTEM � FiNnL �
� f b�ion, you should become subject to the Workers'
C, bensation provisions of�he la6or Code,you must forth- EVqppRATIVE COOLER VALIDATION
wilh comply wiih such p�ovisions or �his permii shall be -
deemed revoked.� � FURNACE: FAU�GR VIT�5 /�� .
LICENSED CONTRACTORS DECLARATION , � FLOOR BTU �o�U�— V �
I hereby afi�rm tho�I am I�censed under pro��s�ons of Chopter 9 HFATER: SUSPENDE� uNit_ �
'(commencing wi�h Settion 7000)of Division 3 of�he Business ' WA�� _
and Professions Code,and my license is in fuil force and effett. S � y� � I �
L�
a
License Number 448349 i;�,cio55 C-20 , ' a
Contmctor- Tnla����� Dote �3� -. . . V
❑ I om exempt under Set. � � . , , . . , ,. ' w
Plan check fee a
h
8.8P.C.for thiz reason' pERM1T ISSUING FEE$ (� z
Date:
S�gnature TOTAL FEE
OWNER-BUItDER DECLARATION PLAN CHEIX APPLIG4NT -
I here6y ai(irm�hat 1 am exempt from ihe Conhactor's License _ � . � �
Law for tha following�eason(Sedion 7D31.5,Business and NnrnE �
� P1-r-o�iessions Code): - . .
I `I, as owner of fhe property, or my empioyees wilh ADDRESS � � .
, ��•�ages es!heir<_ole cemp=nsation,will do the wor4 ond --
� ihe strucrore is not intended or oiiered For sale(Sectian UTV - TE�.NO. �� 2�li H
7044,Business and Professions Code). OWNER Bramalea California, IriC. • • e • e
# 8
❑ I,as owner of Ihe propery,am exclvsively contratling �
with licensed tontroctors to construct the project(Sec- DDRESS 3151 Airway Avenue, SUltfl N � �'' °4 9.7 5
tion 7044,Bosiness ond Professions Code).
� CONSTRUCTION LENDING AGENCY ��TY � COSta tiesa� � �� rei:No.� ��-�- � � -� •• °ll�,7 S�
I hereby afFirm Ihot ihere is a construction lending agenty for
the performance of ihe work far which Ihis permil is issued COMRACTOR � - �� ► D&2 5—8 6 .
(Sec.3097,C��.c.). � Inland ea� i . .. ._ ._..
� nooaess 1696 Commerce Street ' '
Lender's Name �
urr , Co=ona - Te�.No. ..734-4540 .
Lender's Address "
I certif thai I have read�his a lication ond state ihat the SinTE LiC.
y pp uccn,se No. 448349 anss�- C-20 � --- � � . —.. - .
above In(ormation is correcl.I agree to comply with all County � .
ordinances a �Slate laws�eloting to building construction, � � �
and hereby Jrhorize represeMotives of this C nty to enter � � � ' - � - �- � � � � - ��
upon th J v - ntioned properry for in�spe�ian purposes SEE REVERSE FOR EXPLANATORY LANGUAGE -
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