HomeMy WebLinkAbout1191A WORKERS'COMPENSATION DECIARATION APPLICATION FOR PERMIT �
I hereby af(irm thot I hove a ceriifimte of consent to sel( • �. L�
insure,or a cenificare oi Workers'Compansa�ion Insurance, ,bA364c HEATING - VENTILATING - AIR CONDITIONING
or a certified copy�hereof(Sec.3800,lab.C.) �.g�g(REV.10/81J � � - � �� -
Polity No.$jejL'(7j)(yQQDCompany Ai ohl a�nAa �
� �Certified mpy is he�eby fumished. . . � I I �''� � COUNTY OF LOS ANGELES� BUILDING AND SAFETY
i � Certified copy is filed wiih the couMy building inspec- FOR APPLICANT TO FILL IN � BURDiNG l{�p-�
tion department. �vRiNT OR TvvE ONIv) �+DDRE55 V ��J
Daie $/13 APPlicant Inland Htg. iocaurr ,� r `� �
NO. TYPE OF APPLIANCE OR EOl11PMENT - FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' � NEnkESi �� �
COMPENSATION INSURANCE CRO55 ST.
(Tbis�ecrton nsed nof bs eomplefad tI-the work tnvolved 6y ABSORPTION UNIT,BTU Di51RIC1 NO. � PROCESSED BY
the permit it(or ona hundred dollars(SI00)or less.) � qiR HANDLING UNIT,CFM �
I certi(y thal in Ihe performance of�he work for which Ihis �a
permit is issued,I shall nol employ any person in any manner '
so az to become su6ject to ihe Workers'Compensafion Laws. . BOILER,BTU APFROVAlS DAiE INSPECTOR'S SIGNATURE �
Da�e °ppliCanl � COMPRESSOR,8TU ��0`�� �� ROUGH Z zV.d
N�T CE TO APPLICANT: If, oirer meking this Cert�f�cote of VENTIIATION$VSTEM FlP1Al _�7*,�
f �ion, you should 6ecome subject to the Workers'
�C..., ensolion provisions af the labor Code,you must farlh- EVACORATIVE COOLER VALIDATIDN �
. wilh comply with s�ch provisions or this permit sholl be
deemedrevoked. ' . iURNACE: FAU_G IN D Q/1
� LICENSED CONTRACTORS DECLARATION F�OOR aiU �J
�I hereby a(lirm that I om�icensed onder provisions oi Chapter 9 � SUSVENDED UNIT_ -
'(tommencing wilh Settion 7000)of Divisian 3 of the Business HEAiER: WA�� .
ond Professions Code,ond my license is in full force and effect. / }
� a
O
. license Number 4/iR449 Lic.Class C-9(1 - � - - - , � � V�
Canlractor Tnland At�_ Date 8�13 � � � � �
f-
� ❑ I am exempt�nder Sec. . _ _ w
Plan check fee . a
N
8.8P.C.for+h�s reason pERM1715SU1NG FEE S �� � =
Dare:
Signature TOTAL FEE
� OWNER-BUILDER DECLARATION PLAN CHECK APPLICAM
I hereby oifirm that I am ezemp�irom ihe ConhaUor's License
Law for the following reason(Seclion 7031.5, Bosiness and NAME D `1 1 9.9 A
Professions Code): � � .
r'�I, as owner of Ihe p�operly, or my employees with ADORESS �• • • • •$
- .J wages as their sole compensotion,will da ihe work and -
the slruclure is nof infended or o(iered for sale(Seclion CIN TEL.NO. � • •4 9,7 5
7044,Business and Pro(essions Code). -
owNea Bramalea California, Inc. e„ 0 4 9,7 5�
❑ I,as owner of the property,om e.cl�sively conlrading .
with licensed coniroctors 10 con5lroU the project($eo- MA4
tion 7044,Business and Professions Code). ADDRESS 3151 Airway Avenue, Suite N 0 8.2 5�8 6
CONSTRUCTION LENDING AGENCY Utt - TEt.NO. -� -- � - � � .
I hereby affirm thot there is a tonstruction lending agency for Costa Mesa .
the per(ormonre oi the work Tor which this permit is issued CONTRACTOR - -- - � - '
(Sec.3097,Civ.C.). . . . . _ .. _ . . .
� A�DRESS �696 Commerce�Street �� - � - � � - � � � � -� �
Lendei s Name � � .
arr Corona TE�."o. 734-4540 - -
Lende�'s Address
1 certify ihat I hove reod this opplicolion ond state Ihot the LI ENSE NO ���� --�CLASS � - � .__. .. . . .. ... .�. . �
above inform ion is correct.I ogree to comply with all County � �
o�dinonces Stale lews relating to 6uilding cansltuction, � . ,
and h e u4horize represemaiives oF this Coo ty to enter � - - � - -� "� ' " -�-
opon e oJe- e �ioned properly for insppc)1 n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE r. _
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SignoNre of hpplimnr or Agent ote . . .. . . .. . -... . . . .. . .
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