HomeMy WebLinkAbout1207A / WORKERS•�oMPENSAT�oNOE«ARAT�oN � APPLICATION FOR PERMIT �
I hereby affirm that I have a certificate of consent to self A
ins�re,o�a terti{icole of Workers'Compensarion�nsuronce, �bA�bac HEATING - VENTILATING - AIR CONDITIONING �
or a cerrified copy rhereof(Sec.390p,Lob.C.) cE-ela(REV.l0/91�- � -� �- � � � �
Folicy NrI�WC604000Compa�y Hi�hlands
❑ Ce��ified copy is hereby furnished. )�'�y COUNTY OF LOS ANGELES: BUILDING AND SAFETY
�CCertified copy is filed with�he to�nty b�ilding inspeo- FOR APPLICANT TO FILL IN BUILDING ��
• tlOn deparlm2nf. (PRIM OR TYPE ONLY) AD�RES$ ,
Date S/13 APPiiconf IR�.aild HtQ. �ocnun "'i"��.t" l.�a�� �
NO. TYPE OF APPLIANCE OR EOUIPMENT FEE
CERTIFICATE OF EXEMPiION FROM WORKERS' � NEnREST �
COMPENSATION INSURANCE . CRO55 ST.
(This�seclion need nof 6e complalsd if 1he work involved by ABSORPTION UNIT,BTU Di57RiCi NO. PROCESSED BY
fhe permil is for one h�ndred dollars(5100)or less.) p�R HANDLING UNIT,CFM I�
I certify thot in Ihe performance of ihe work for which thiz
permit is issued,I shall nor employ any person in any manner
- so as lo betome subjeU 10 Iha Workers'Compensalion laws. BOItER,BN qPPqpVAlS UqiE INSPfC70R'S S�GNATURE --
Date � /pplicant I COMPRESSOR,BTU � Qv ROUGH �V i ✓
Nni10E TO APPLICP.NT: If, ofler mokinq thi5 CE��i(iCa�e of VEMILATION SYSTFM FINAt �Zf��
( �fion, you should bemme subject 10 the Workers'
C._penso�ion provisions of the Labor Gode,you mus�for�h- EvqppRqTIVE COOtEe . VALIDATION
with comply with such provisions or this permit�shall be
deemed revoked. I FURNACF. FAU G I /�/��
-LICENSED CONTRACTORS DECLARATION l FLOOR BTu D l��
i hereby af(irm that I am licensed under provisions of Chap�er 9 HEAhR:� SUS�hIOED � UNiT_ - .
'(commencing with Section 7000)of Division 3 0(fhe Business � �'�'A« �
ond Professions Code,and my license is in full force and effetl. . . �'
1 � � d
lrcense Number 448349 'i��.cioss C-20 , �
Conrrecror Inland Htg. De�e $�13 O
❑ I om exempt under Sec. ._ . . _ __ __ w
Plan check fee a
B.&P.C.for this reason� � �
PERMIT ISSUING FEE S U z
Date:
signo�ure TOTAL FEE
OWNER-BUIIDER DECLARATION PLAN CHECK APPLKAM
I hereby oifirm Iha�I am exempt from the ConlraUor's License � fi� �Q 7�
law for ihe following reason(Section 7031.5, Bo5ine55 ond NAME , �
Proiesslons Code): � �•��• • • •F3�
r�l, as owner of the properly, or my emplayees with ADDRES$
� J wages as thei�sole compensation,will do the work and CITY TEL.NO. � • °�a�5
the sh�cl�re is nol intended or ofiered ior sale(Secfion �_
7044,Basiness and Professions Code). . - . � e s •rj�2,>>
pWNER
❑ I,os owner oi the property,am exclusvely controcting � � � O H 2 5—H 6
wi�h I�censed contractors m conshod�he project(Set- DDRE55 3151-Airway Avenue, Suite�N �
tion 7044,Buzinezs and Prafessions Code�.
�ONSTRUCTION LENDING AGENCY ' ��n' Costa Mesa - ���"o. �-�� �-�� �
I hereby affirm that�here is a constroction lending agency(or ' -�
the performance of the work for which ihis permit is issued- CONTRACTOR � � � � �- ��-- �
(Sec.3097.Civ.C.). In �
__. .. ..... . .... _ .._ .. . .
� ADDRESS 1696 Commerce Street --�-- -- --- - � -�- � � � � - � �
- Lender's Name �
arr orona re�.No. .734-4540
lender's Address
� STATE LIC.
I certify ihal I have read this opp��totion and s�ote that�he ' uCENSE NO. !y[�$3L�9 CtASS - —2 -��-� ����� -�--- ---� - --_ .. . . . . � . .
a6ove iniormation is corred.I agrea to comply wi�h all Caunty . �
ordinanc and S�ate laws reloting 10 building c nstrudion, _.. �
ond he outhorize representotives of this Cou ty fo enler ' . � � - � � �� -� ��� .
vpo /b � -men�ioned property for ins urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE .
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