HomeMy WebLinkAbout1218A WORKERS'COMPENSATIONDECLARAiION , � APPLICATION FOR �PERMIT �L �
I hereby offhm�hat I have a tertificote of tonsent to self
insure,or o certifitote of Workeri Compensa�ion Insurance, �bA��� HEATING - VENTILATING - AIR CONDITIONING
or a cenified topy thereof(Sec.3800,Lab.C.) � -GE-ele�REv.t0iel) �
Paolicy No.BWC6O4OO�omPo�Y Highlands � �y,� � -� - � �
Ce�tified copy is hereby f�rnished. I�-Jf 1 COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Cerrifed copy is filed wHh the county building inspeo- FOR APPLICANT TO FILL IN BUIIDING �-C1 1
tion deparfinent. � � (PRINT OR TYPE ONLY) ADDRESS �l i
Date R/�1'3/R(, APPlimnt Tyll�td Fjt� . LOCAtITV �`Y
. NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
� COMPENSATION INSURANCE CRO55 SL t l7'}`
(ihl�sactlon n�ad nol 6a tomplsted I(Iha work tnvolvad 6y ABSORPTION UNii,eiU DISfRiCI NO. PRO�ESSED 9Y
fha permtt i�for one hundrod dollan{SIUO)or less.) - qiR HANDLING UNIT,CFM � ' 1!` ��/�
I certify that in Ihe performante of the work for which lhis . J`� �v ,
permit is issued,I sholl not employ any person in any manner -
so as to 6ecome subjeU�o the Workers'Compensation Lav✓s. BOILER,BTU APPROVAlS ' DATE INSFECTO4'SSIGNATURE -�-�
Date Applicanl� - � COMPRESSOR,BiU ��`1��� `Q G� RpUGH /zl6�6
f'�-(CE TO APPLICANT: If, ofler making this�Certificate of VENTILATION SYSTEM FINAL �7 �,'
�ptlon, yoo should 6ecome subjed to the Workeri
Compensolion provisions o(the Lobor Code,you musf forth- EVAPORATIVE COOIER VALIDATION
wllh tomply with s�ch provisions or fhis permif sholl be�
deemed revoked. . � � � � � FURNACE: FAU_Gg pVIiY �
IICENSED CONTRACTORS DECLARATION � 1 FtOOR eTu `IX,/`f�7 � �
I here6y ofiirm that I om licensed under provisions ot Chopter 9 SUSPENDED UNIT_
HEATFR:
'(commencing wilh Section 7000)of Division 3 of the Business WA« }
and Professions Code,and my license is in full force and effect. 1 � i L ' a
448349 � � O
License Number Lic.Closs C-2� � � . , � . U
Contratlor IIIlHrid Htg. Date 8�13 F
O
.❑ I am ezempt unde�Sec. , w
Plan check fee y
B.8P.C.for this reason PERMIT ISSUING FEE$ � 5 Z
Date:
Sgnoture TOTAL FEE ��j g s
� � OWNER-BUILDER DECLARATION PLNN CHECK APPIICANT � 2�,8 a
I hereby affirm ihot I om exempt from�he Contracmr's License . , �.�� e . .8
Law for�he following reoson(Section 7037.5,Business and NnME .
Professtons Code): - - �� � -� . � v y�z�2 JF
.��I, os owner of thc prcperty, or my rmplayres with ADDRESS . . '
wages as their sole tompensotion,will do the wark ond ��N TE� � e x e��2��
the struc�ure is not intended or ofFered for sala(Settion
70d4,Business ond Professions Code). � -� ' � O S.�L J�Q,6
OWNFR grar�alea California lnc. �
❑ I,os owner of�he property,om ezclusively contracting
wilh licensed tonhactors to construct Ihe project(Sec- qD�RE55 3151 Airway Avenue, Suite N �
-� �ion 7044,Businees and Professions Code).
CONSTRUCTION IEN�ING AGENCY �. Citt COSCa MOSd � TEI:NO. � �-
I hereby oHirm ihat�here is a construclion lending agency for , �
the performonce of Ihe work for which this permil is issved- �pMRnGTOR Inland Heatin IttC.
(Sec.3097.Civ.C.). . --. ... . .
nooRess 1696 Commerce Street � " '
Lender's Name
a1r Corona rE�.No. .734-4540
Lender's Address
� - STATE _ LIC. .
I certify that I hvve read�his applica�ion and state thal the uceNse n,o. 44834y Cu55 -C-L� � -� � ���- -�- �---� � . . . .. .
obove info� tion is corred.I agree to comply with all County
ordinan�e and Stale lows relating to building construclion,.
and er y auth ize representalives of ihis ouMy to enfer . � � � � � � - � �� -� � - �
upo t bav m ntianed property for i� cfion pwposes. SEE REVERSE FOR EXPLANATORY LANGUAGE _ ..
Signarore o1 AppGcant or Age�� �v�e . . . . . . . .. . . ..
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