HomeMy WebLinkAbout1221A 1190A WORKERS'COMPENSATION DECLARATION �. APPLICATION FOR P�RMIT �
I hereby of(irm�hat I have a certiiim�e of consent to self , �
;,,,��e,o�a cerlificale of Workers'Compensation i����a��e, HEATING - VENTILATING - AIR CONDITIONING Z �ti
or a certified copy Ihereof�Sec.3800,Lab.C.) 75A36aC .� .
CE-019(REV:10i81) . .- . .... . ... .
a�y rio$�LG604000Compony Hi�hlands •
Certified copy is hereby furnished. COUNTY OF LO$ANGELES.. BUILDING AND SAFETY
�, Cer�ified copy is filed wiih rhe counry bu�ldtng inspec- FOR APPLICANT TO FILL IN BUILDiNG I. -
fion de artmenf. . ADDRE55
P (PRIM OR TVPE ONLY),
Date $�13 � Applicanl Inland Htg. ianurv I'f
� NO. TVPE OF AVPLIANCE OR EQVIPMENT � � FEE�
CERTIFICATE OF EXEMPTION FROM WORKER$' NenaESi . .
' COMPENSATION INSURANCE� cRO555T.
(This saction nead noY be complalad if fhs work fnvolved by ABSORPTION UNIT,9TU Oi5/RICi NO. �Rp�E55FD BY
tho permit is(or ona h�ndred dollars(5100)or le�s.)
I cerfify ihol in ihe performance of Ihe work for whkh ihis� AIR HANOLING UNIT,GFM I tl
permit is issued,I shall not employ any person in any manner gpitER,BTU -�
— , so as to become subject to�he Workers'Compensation Laws.- avovovnts DATE INSPECTOR'$SIGNAiURE
- COMPRESSOR,BTU �D O� ROUGH �2(y v
Da1e APPlicanl
NM CE TO APPLICANT: If, a{ler making Ihis Certificole of VENTIL4TION SYSTEM FINAt , �y)
F lion, you should become subjett fo 1he Workers'
C.._.�ensation provisions of the labor Code,you must forlh• EVAPORATIVE COOLER ' VALIDATION
with tomply with such provisions or this perml�sholl be
- deemed revoked. � FURNACE: FAU_G Vli O
. ' IICENSED CONTRACTORS DECIARATION I FtOOR BTU
I hereby affirm thot I am licensed under provisions of Chopler 9 HEATfR: SUSPENDED UNIT_ � �
'(commenting with Section 7000)of Division 3 of the Business �wA«' }
and Professions Code,and my license is tn full force and effecl. _ I —�' �`h � � O, -
L�1 �� ZZ,jR V
� License Number 4GR'�49 Lie.Class C-2D � � �'�� � � ► .
;!e • v. :g a .
Commctor Tnland Htg_ Oere ��13 d
❑ u
I am exempt under Se[. � ' '4 9��5 a
Plan check fee
B.BP.C.for this reason- I . � � e s 4 9,7 5 c=.� � Z
PERMIT ISSUING PEE S
ome: 0825-86
• TOTAL PEE
Signa�ure - - .`�
OWNER-BURDER DECLARATION PIAN CHECK APPLIC4NT � � V(
I he�eby ailirm tha�I om exempt(rom the CoNroUor's license . �\� �n, , 9 O �
Low for ihe foilowing reason(Setlion 7031.5, Business and NnME . � � �. � .�+.� � y�
Professions Code): �
��I, os owner of ihe property, or my employees wilh ADDRESS- ��� � � - � � ��f i 4
.85
.�.wages as their sole mmpensatian,will do the work and �
ihe strudore is not intended or offered for sale(SeUion C�TM TEL.NO. r ' e 4 9,�5�
7044,Business ond Professions Code). . OwNER
❑ I,os owner of the property,om exclusively contracting Bramalea California, IriC. �$2 5—8 6
wi�h licensed confractors to construd ihe projeU(Seo- � ���
tion 7044,Business and Professions Code). ADDRESS 3151 Aixway Avenue, Suite N .
CONSTRUCTION LENOING AGENCY ��r �Costa Mesa� '���"o. �� � �
I her¢by affirm thot there is a conshuction lending agency for � �
the performance of the work for which this permit is issued �ONTRAGTOR Inland H�-
(Sec.3097,Civ.C.).� . .. . .. . - . . - . . .
� ADpRE55 1696 Commerce Street. � - � � � � . � �
Lender's Nome
aTv Corona 'E� "o. 724-4540 - - -
Lender i Address � �
� STATE L�C.
I cerfify ihal I have read this applicotion ond state thot the LICENSE NO. ��- CLASS� C—LO ��� -- - ---- - �� ----� -
� above informa�ion is correct.I ogree�o comply wiih all Couny
�� ordinan[es a $tale laws reloting 10 bvilding construclion, . . , _ _ . ,. , _ .. , . , ._ _ _ . _
and he b horize representofives of lhis Cou ty to enler �
upon i . v�e- ntioned property for insp n porposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
� .
Signature of Appl�canf er AgeM . Dale - � . � .. . . . . .. . .. . . . . �
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