HomeMy WebLinkAbout1205A WORKERs�oMPENSAT�oNOE«AQAT�oN - � APPLICATION FOR PERMIT � `"� �
I hereby affhm thol I hava d cer�ificare of consent fo self . � �
insure,or a certi(icate of Workers'Compensotion i„5�.a��a, HEATING - VENTILATING - AIR CONDITIONING
o.a ceriified cqpy�hereof(Sec.3800,1a6.C.) 7anseac .
BWC60400n Hi hlands CE-818(REV.10/81)
� Polity No. Lompany g -- � �
❑ CertiFied copy is herehy furnished. 1 t3` COUNTY OF LOS ANGELE$ .-.... . BUILDING AND SAFETY
� Certified topy is filed wtih rhe tounty 6uildfng inspeo- FOR APPLICANT TO FILL IN sunowG ��Tl
tion deparfinenf. . ADDRESS V �
(CRINT OR TYPE ONLY)
Doie 8/13 APPlicant Inland Htg. �ocnun
. NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS � NEaaEST �
- COMPENSATION INSURANCE CRO55 ST.
(Thts sadton need not be completed iF the work tnvolred by ABSORPTION UNIT,'erU DiSiRi�i NO. P40CFSSFD BY
tha permll ls for one hundrad dollars(5100)or lass.) �
AIR HAN�IING UNIT,CFM O
I ce�tify that in the performance oi the work for which this .
.permit Is Issued,I shall not employ any person in any monner
sa as to become sobjett to�he Warkers'Compensalion laws. BOiLER,BTU APPROVALS DATE - iNSFECT04"S SIGNATURE —
Date � Applicanl � COMPRE55012,87U ROUGH /z•L4
Nr'T�CE TO APPLICANi: If, after making this Certificafe of VENTiIATION SYSTEM FINAL y `
' Lon, you shovld become subject to 1ha Workers'
� C.... ensa�ion provisions of Ihe Lobor Code,you must forth- EVqpORATIVE COOLER � VALIDATION
wiih comply wilh s�ch provisions or this permit shall be
deemed revoked. - . - FURNACF: FAU_ VIT /� �
� �UCENSED CONTRACTORS DECIARATION . � FtOOR BiU OV . .
I hereby offirm that I om licensed under provisions of Chapler 9 HEATER: SUSPENDED UNIT_ � �
'(commencing with Section 7000)of Division 3 of ihe Business ' '''�A« �
and Professtons Code,and my license is in full force and ef(ecl. � !1 . a
�J Q
License Number 448349 ��c Class C-20 ' V
a
Contractor inland Htg. Dote $�13 O
❑ I om exemp�under Sec. . V
Plan check fee w
a
B.BP.C.for this reason� N
PERMIT ISSUING FEE S =
Da�e:
TOTAL FEE
Signalure
OWNER-BUIIDER DECLARATION PL/+N CHECK APvIICaNT � '
I hereby affirm that I am exempt from the Controctoi s litense . � �
Law for the following reason(Section 7031.5,B�siness ond NAME
Professions Code�:- . � � . `� 2 a 5�.
�}I, as owner of the property, or my employees with ADDRE55 - �� �
..,. oges os�heir sole tompensotion,will do the wcrk ond - ��• �8
Ihe strucl�re is not inlended or oifered for sale($ettion CITV TEL.NO.
7044,Business and Professions Code).• � � . � - � � � • •4 9.7 5
- rnroNER Bramalea California; Inc. -
❑ I,as owner of the property,am exdusively conirocting � � ,• ^ ^�:Q.�Jr c�a
wilh licensed tomroclors to construU the project(Sec-� ADDRFSS 3151 Airwa Avenue Suite N
-lion 7044,Business and Pro(essions Code). D S.C Jr"�i�7
CONSTRUCTION LENDING AGENCY - � Ci1Y Costa Mesa TEL.NO.-� - - "�-�--' - .
I hereby affirm that there is a construciian lending ogenty for ►
the performance of Ihe work for which ihis permit is iss�ed CONTRA�TOR Inland Heating, TIIC.- "
(Sec 3097,�iv.C.). � .. .. . . . - . ...... .. .
- ADDRESS 1696 Commerce Street � �� � ��- � ��� � �
lender's Name �
urr Tei.rro. -4 40 . _ . _ . _.
lender's Address
STATE tIC.
I ce�tify thal I have read thh opplitolfon and stole Ihaf Ihe UCENSE NO. -- -� CtA55 � -- _ -- -- -- � - - � - ��� �� -� - - -- -
obove inior ation is correU.I agree to comply with all County . .
ordinonce bnd Stote IowS relol(ng ta building con5hoc�io�, � _ � , . .. ._ . . . ,
and h r. y aulh rize represen�atives of this Coun y ro eNer - -
upon h. ov entioned property for insp�o p rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE_ . .
Signa ure of ApPlicani or Agent � Da e . . . ....... . �.-. . .... . . _ . .
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