HomeMy WebLinkAbout1208A WORKERS'COMPENSATIONDECIARATION �� � /�y���ICATION FOR PERMIT � �
I hereby affkm that I have a certificate of consent to self �
insure,or a certifcate of Worke�s'Compensarion�nsurance, 76A3eac - HEATING = VENTILATING - AIR CONDITIONING � t1
or a certified capy Ihereof(Sec.3800,Lab.C.� . , . _ ,
CE•B18�REV.10/81) �
OcyNoBWC604000�ompany H3ghlattds '
Cer�ifed copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
�Ceriified copy is filed with�he covnry building inspeo- FOR APPLICANT TO FILL IN Bu�LoiNG � [�
fian department. ADDRE55 1
. (PRINT OR TYPE ONLY)
oo+e ' 8/13/ APPlicanl Inland Htg._ ��"��TM . �
.NO. TVPE OF APPLIANCE OR EOUIDMENT � FEE _
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST �
� � COMPENSATIONINSURANCE CROSSST. .�
(This ssetlon need not ba complatod if 1l�a work involvod by ABSORPTION UNIT,BTU DISiRICT NO. PRp�[$$ED BY
Ihe permlt is for ona hundred dollors(f100)or las�.) 1�{
I cerlify that in the performante of the work for which this A�R HAN�LING UNIT,CFM �U ,
permit is issoed,I shall not employ any person In any manner gOiLER,BTU --��
so os to betome subject to rhe Workeri Compensation Laws. � avvaOvnlS �DA7E iNsa�croa•5 siar+nruae
COMPRESSOR,BTU O 1O W ROUGH Z�V.�,
Date APPIfmN �
NnTICE TO APPLICANT: If, afler making this Cerlificate of � - VENTILATIONSYSTEM FINAL ��..7
[ �ion, you should hecome subject to the Workers'
C.._ ensatian provisions of the Labor Code,yoo mus�/odh- EVAFpRA71VE COOtER VALIDATION
with comply with such provisions or ihis pe�mit shall be �
deemed revoked. FURNACE: fAU G VITY /�/ti
IICENSED CONTRACTORS DECIARATION I FLooR BTU O �..��� �
I hereby affirm tha�I am licensed undAr provisions of Chap�er9 HEATER: SUSPENDED UNIT-
'(commencing wilh Seclion 7000)of Division 3 of iha Business WAtL .
ond Professions Code,and my license is In full fvrce and effecl. ---�� � y
license Number 448349 �;�.cia„C-20 , �
v
oe
co���o��o� Inland ht�. oo�e 8/13 . �
�.
❑. i am e*empt onder Sec. . . . . ... V
Plan check fee W
a
�
B.BP.C.for rhis reoson� Z �
PERMIT ISSUING FEE S D •
Dote:
Signarure TOTAL FEE 3
OWNER-BUILDER DECLARATION aAN CHECK APPLICANT -
I hereby aflirm that I am ezempf from the Controctor's litense . D ,
law for the following reason(Section 7031.5,Business and NAME .
Professions Code): . � �� 2 a$�
r I, as owner of�he properry, or my employees wifh� AD�RESS - � � - - � � � - - -� � � � �-
-' ,woges as their sola compensolion,will do the work and H •8
the shodure is nol in�ended or offered 1or sale(Section Ciiv TEI.NO.
� 7044,Business ond Professions Code). � . � � I e �J��S
OWNER g=amalea California, Inc.
❑ I,as owner of the proper�y,am e�tlusively conlratling MA L � . 'Jr 3.2�c=i
with licensed confractors to conslruct Ihe project(Sec- qDDRESS 3151 Airwa Avenne Suite N ^A
tion 7044,Business and Professions Code�. , O��z Jr�a�7
CONSTRUCTION LEN�ING AGENCY -� CiTv � � - TEC.NO: -� - -'- ' �
I hereby aifirm Ihot there is a conshudion lending agency for Cos ta Mesa- �
the performonce of the work for which Ihis permit is issued COMRaCTOR Inland Heating, IriC�.-"- "- �� , � -
(Set.3097,Civ.C.). - . .. - .. . ... . � .
� � ADDRESS 1696 Commerce Street� � �� � � ���� � � �� � �� -� - -
lender's Nama �
arv rei.No. 4-4 40 _
Lender's Address
I certify that I have reod this applimtion and state that�he iic�r'�,se n,o 448349 _ _ . ....�.�LA55... C-20._..._ .
__ .__ . . _. __ .. _.._.._ .. .
above informa�ion is correct.I agree�o comply wiih all Counn�
o�dinances �d S�a�e lows relating to building tonshudion, , , , . . . . . .. . . . . .. . ..... .. __ . . . . . ,. . , . , , .
� ond h b du�h rize representatives oi Ihis Co nty to enter � . .
upo entioned property for insµe�� n purposes SEE REVERSE FOR EXPLANATORY LANGUAGE __
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