HomeMy WebLinkAbout1219A WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT 44 �
I hereby a(FNm thal I have a cerliilcale of consent to self .
insure,or a certificate of Workeri Compensaiion Ins�rance, HEATING - VENTILATING - AIR CONDITIONING �S
or a certified copy Ihe�eoi(Sec.3800,Lab.C.) � 76A96aC �
CE-el B(REV.10/81)
. Poli[yNoBWC6O�iOOOCompany Nighlandc �
❑ Certified copy is he�eby furnished.. 11�` COUNTY OF LOS ANGELES BUILDING AND SAFETY
�i� � Ceitified copy is filed with the county.building inspec- FOR APPLICANT TO FILL IN �� �� BUitDtNG �� /�..
ADDRESS L,(�J
lion deparfinent. . (PRINT OR TYPE ONLY) ,
Date 8�13 Applicanl Inland HtQ. LOCALITY .t- L` .
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKER$' NEaREST �� L �
�COMPENSATION INSURANCE . CRO55 ST.
. (This ssetlon neod not 6a complatod if tha work involvad by ABSORPTION UNIT,BTU Di5141CI NO. VRp�E55ED BY
flle permit is for one hundred dollors(S100J or Iass.J � qIR HANDLING UNIT,CFM /( , . ,l`
I certify�ho�in the performance of the work for whith this �J •� 1
permit is issaed,I shall not employ any person in ony manner
— so as�o bemme subjecl to Ihe Workers'Compensalion Laws. BOILER,BTII APPROY0.l5 �ATE INSPECIOR'S SIGNAfURE --
Date - Applitanf � . . COMPRESSOR.BTU ���1�l,l� ID �/ ROUGH �j•/(��
N^TICE 10 APPLICANT: If, aNer making �his Ceriificate of VEN11tATION5Y5TEM . FlNAL � �,����
f `f�n,.you sho�ld become subjecl to the Workers'
C,._.pensotion provisions of ihe Labor Code,you m�5��Orlh- EVAPpRATIVE COOIER VALIDATION
� with comply wilh suth provisions or lhis permif shall be �
deemed revoked. � FURNACE: FAU_ VI Y /a/� �
LICENSED CONTRACTORS DECLARATION I FIOOR BTU Q �-�i �
��
I hereby affirm fhat I am licensed under provisions of Chapter 9 - HEAhR: SUS�N�ED UNIT_
'(commenting with Section 70W)of Division 3 of tha Bustness ' wALL ,
ond Professions Cade,and my license ie in full force ond effecL �� � y
3 0
l�cense Number 448349 Lic.Closs C-20 . V
�
Conirocror Inland Htg. Dote 8�13 �
�
❑ I am exempf onder Set. ' ' . .. . . .. . � . �
Plan check fee W
B.BP.C.for Ihis reason� a
PERMIT ISSUING FEE S a z
Date: _
��: TOTAL FEE
signature . .
- OWNER-BUILDER DECLARATION PInN CHECK APPIICANT
I hereby affirm thoi I om eKempt from the Con�ractor's licen:e� � � �
Low for the fallawing reoson(Setlion 7031.5,Business and NnME .
Professions Code): -
r\}� 7;owner of Ihe properly, or my employees wilh ADDRESS .
_J-�i�9es os Iheir sole compensation,will do the wcrk and CITY TEL.r10. �� 2�.9 a
the sMudure is aot iniended oi oHered for sole(SeUion
7044,BuSinesS ond Professions Code). ��ER � - . ���a • o e 8
Bramalea California, Inc.
❑ I,as owner of the proper�y,am exclusively contracting .
with licensed coniroclors to tonstruct ihe projecl�Set- DDRE55 3151 Airwa Avenue �Suite N . I �» •5 a 2 5
tion 7044,8usiness and Professions Code). � ,
CONSTRUCTION LENDING AGENCY . dTY " ��TEL NO.� "' - � " s.a�e j j Q 5�
I he�eby affirm that there is a conshuttion lending agency for
the perfo�monre of the work for which this permit is issued �-� CONTRACTOR Inland�Heating,� Inc.-�� �� �� ► 0 8.2 5=8 6
� (Sec.3097.Civ.C.). - .._ . _ . . . . . .- -
- � ADDRESS • � - -
1696 Commerce Street - - -- �
. Lender's Name
an Corona - TEi."o. ..734-4540
...-- .._. ._. ....
• Lender's Address
. STATE 448349 "�� C-20 �
I certify ihat I hove read this appliwtion and sla�e Iha�the uceNse No. anss - - --
above informa�ion is correct.I agree to comply with all Counry �
ordinant and Stale laws relaling to boilding conslruclion, . . ._ . _ . _ , _ . _ , . . _
an �h i y a orize representotives of this Co ty to enter .
op bo -mentioned properly for insp�ti n purposes. SEE REVERSE FOR ExPLANATORY LANGUAGE
Sig a�ure of Applican�or Agem Da�e . . . .. .- . _. . . � - .. . . .. . . .
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