HomeMy WebLinkAbout1206A WORKERS'COMPENSATIONDECLARATION • APPLICATION FOR PERMIT �� � �
I hereby offirm tha�I hove a certificate of consent to self .
ins�re,or a ceriificote of Workers'Gompenso�ion lnsuronce, ���� _ ,HEATING - VENTILATING - AIR CONDITIONING
oracertified cnp"thereof(Set.3800,Lob.C.) � CE-B�e�REV.�10/6�) �� - �- -����- �
O�Y NoBWC6�4000ComPany Highlands
CertiFied copy is heraby furnished. LOUNTY OF LO$ANGELES BUILDING AND SAFETY
� Certified copy is filed with the county buiiding inspec- FOR APPLICANT TO FILL IN , BUnoitv� ��"i� �
tion deportmeM. - � AD�RESS �J (Q
8/13 Inland Ht . (PRINT OR TYPE ONLY) �p�ALITY
Dote �ApplitoM g � �
NO. TYPE OF APPIIANCE OR EQUI7MENT . FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST �
� COMPENSATION INSURANCE CROSS ST.
(Tht��.ct�on nead not be tomplulad if Iha work involv�d 6y /+g50RPTION UNIT,BTU DISIRIC!NO. GROQ55E�9Y
tba permlt fs(o�one h�ndrad doilan(5100)or le�s.) � AIR HANDLING UNIT,CfM -
I certify�hat in the performan[e of Ihe wo�k for which Ihis��- I O '
permif is issued,I shall not employ any person in any manner BORER,aTU
so os�o become s�bject to ihe Worke�i Compenso�ion Laws. ncvcovn�s ont INSPECTOR'S SIGNANRE -�
Da1a Applicanl COMPRESSOR,BTU�r J � ROU6H Iy�/(�:fG
Nf'TICE i0 APPLICANT: If, aTter making Ihis Cerlificate of VENTILATION SYSTEM FINAL . �) "
—� bhon, you should become sobject to the Workers'
C....¢ensation pro�isions of ihe lobor Code,yov must forth- EVAPORATIVE COOIER VALIDATION
wilh comply with suth p�ovisions or this permit shall be �
deemed revoked. � � . FURNACE: FAV_�R VIT
� IICEN$ED CONTRACTORS�ECIARATION 1 FLOOR BTU - U� �
I hereby ofiirm thot I am Iicensed under provisions of Chopter 9 SUS7ENDED UNIT_
'(commencing with Section 7000)of Division 3 of ihe Bvsiness HEATER: WA��
ond Pro(essions Code,and my license is fn full force ond effect. y
�icense Number 448349 ���.�loss C-20 � -- , v
m
Contracror Tnland Htg_ Dare R�13 �
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I om exemp�under Sec. u+
Plan check fee . N
_ e.av.c.ro.�n�:��so� PERMIT ISSUING FEE S � --
�o+e:
Signorore TOTAL FEE
. OWNER•BUILDER DECLARATION PLAN CHECK A7PLICANT '
I hereby offirm Ihat I am exempt from the Cvntrocror's licensa � �
law for the following�eoson(SeUion 7031.5,Business ond NAME � �
Prof\essions Code): . �� 2 Q b A
r yl, os owner of�he property, or my employees wi�h /+DDRE55 � .
f wages as�heir so�e compensotion,w�ll do the work and �T� � � � �s -
the srructure is not intended or offerecJ for sale(Section CiTY TEL.NO.
7D44,Business and Professions Code�. - • I�� °�l 9 7 5
OWNER
❑ �I,as owner of the property,om ezclusively contrading � �e a x
wi�h licensed controctors�o cons�rvct the projecf(Sec- qpoeE55 3151 Airway Avenue, Suite N �� 4 9,7 5 c>
� � tion 7044,8vsiness and Proiessians Code). O B Z J"�6 -
CONSTRUCTION LENDING AGENCY . � � ��ry COSCa P10S8 . 1EL,NO. " - �-
I hereby affirm that ihere is a construclion lending agency for
the performante of the work far whith Ihis permil is issued CONTRACTOR ' '"- � �
(Sec.3097,Civ.C.). IA an ' ,...
- � ADORE55 1696 Commerce Street � � - � - -� � - � �� - � � - -
Lender's Name
arv Corona rEi."o. 734-4540 -
lender's Address .
I cer�ify thot I ave read this oppiicaiion and sta�e Ihol the icen;se No. 448349 �i 55 C—�� _
ebove info�m i n is correct.I agree 7o comply wilh all Counry
o dI herees o�d�S�o�e laws relating to building tonsl�uUion, _ � _ �
tiorize representotives of�hi�Covnty to eNer � � � � � ��� � �
upon th n v�- rioned property for tj3 ction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE _
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