HomeMy WebLinkAbout1169A (5) WORKERS'COMPENSATION DECLARATION �y
� OPPIIPOTIAN FnR PFRMIT 1!
n"—.'c4iirm ihci ; ncve-ceriincair o�[or�sani io s�i� . �:' " ="�e '"e="� ' ='c ' -�""e'""
j ��e �e���r��are af wo�ke�s Compensation ins„r�n�e, ,bA364� HEATING - VENTILATING - AIR CONDITIONING �
� ��rtifi d copy ihereof(Sec.3800,Lab.C.) � .
�CE-876 fREV,l0/81)
Company COUNTY OF LOS ANGELE$ BUILDING AND SAFETY
� Cer ied copy is hereby fvrnished. �
� ertified copy is filed wiih the county building inspeo FOR APPLICANT TO FILL IN BUIIDING
tion deparimenY. (PRINT OR TYPF ONLY) pDDRE55�
Date Applicant .... -- ---- LOC IT �y�y�f� f ua G.l C'O U4T�'
NO. TYPE OF APPLIANCE OR EQUIPMENT � � FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' Nenaesi .
COMPENSATION INSURANCE CR�555i.G C�j'1!!A'% �Q/�7oH �
(This section need not be completed if fhe work involved 6y � � /+aSORPiION UNIi,BiU uistuia No. � N.�octsse er
fhe permit is For one hundred do�lars($100)or less.) n�d �.
I certify that in the performance of ihe work for which this ��H H�NDu�G uNii,c5ti. /y/j n „
L.�t/Gwe'��
permit is issued,I shall not employ any person in any manner n d
so as to bemme subjeU to the Warkers'Compensation Laws. / 601LER,6TU nvaeCvais oare wsaecroa's SicNnruse
COMPRESSOR,BTUZ-19,000 BTU A/C ROUGH
Date � Applimni .
NOTICE TO APPLICANT: If, after making ihis Certificate of VENTILFlTION SYSTEM Forced Ai r FINaL '...f�p f T'� _
Exemption, yo� sho�ld become subject to ihe Workers' - _ -
Compensafion�,�o��s�ons of rhe tabo�Code,you musr forrh- n�� evnPoaArive coo�ee VALIDA710N
with mmply with such provisions or this permii shall be
deemed revoked. �/a FURNAC[: FAU_GRAVITY
. .--LICENSfD-CONTRRC7[�RS DECtARJiTtOPk-.--- �--ELODR BN___—. ._ �.
I hereby affirm ihat I am licensed under provisions of Chppier 9 HEATEk: SUSPENDED UNIT_
�(commencing wiih Section 7000)of Division 3 oF Ihe Business - - WALL �
nnd Professions Code,nnd my license is in full force and effeci. j�{�dt 'l.�UI11�J �'
�
License Number _Lic.Gass • ► �
f' �' '�S �
Contrador Date �
❑ I pm exempi under Sec. �
Plan check fee �
8.8P.C.far this reason � �
PERMI7 ISSUING FEE S
te
` TOTAL FEE
Sig t yt ,
- WNER-6UILDER DECL/1RATION PLAN CHECK APPLICANT �
I her 6y a "m th�l I nm exempt from the Contracior's License � ►
Law , t e followinq reason(Sedion 7031.5, Business and NAME 'o-�1i11 iams�Te'ecc�;�murications C0.
Professions Code): �-
❑ 1, as owner ofi the property, or my employees with A�DRE55 9743 Cherry�Avenue - � 4�1 i 6,9 A
"'age�as,he�,soie�°",Pe�s°'�o",'"�iido'he""ork°"d or� Fontana,CA 92335 TE�.No.714-350-04�1 #• e s a •g
the siruciure is noi irdended or offered for sale(Section .
. 7044,Business ond Professions Code). � OWNER �til��7 dI11S 7e1 ecommun i cati ons C0. � e a J'7,5�
❑ I,ps owner of ihe property,�m exdusively confracting MAIL
with licensed coNracfors to mnsiruct the projecf(Sec- p,Q, $OX 21348 • 0 ��{ft.u G u
lion 7044,Business and Professions Code). ADDRESS
cor,srRucr�or,�eNo�Nc a�eNcv c�TY Tul sa, QK 74121 TE�.No.gl8-588-3397 I 2 1 9-8 ts
I hereby affirm ihat there is a consiruction lending ogency for -
ihe perfarmance of the work for which this permit is issued COnIteACTORASSOC, COYIC. Prod,-C1 int Thorson�:►
(Sec.3097,Civ.C.J. �
aooeess 4301 ba, i�icArthur Blvd. --
Lender's Name
��TY Santa Ana,CA 92740�E� NoJl4-557-2170
Lender's Address
I certify ihat I have read ihis applicaiion�nd siote ihat the �C NSE NO- 27235� C�P.SS1st C�d5S-Uil�l 1�2C� _ , _
above information is mrrect.I agree to mmply with all Counry� -
ordin�nces ond St�ie laws reloting to bullding consirudion, .
o d hereb authori<e representatives of this County to enfer . � �� � ��
upo i u ve- e 'Po`e roperty for inspection purposes. . SEE REVERSE FOR EXPLANATORY LANGUAGE �
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