HomeMy WebLinkAbout1153A (5) WORKERS'COMPENSATION�ECLARATION �
I here6y atfirm�ha1 I hove a certifitate of�o�,e���o,e�f . APPLICATION �FOR PERMIT .
insure,or a certifimte oi Workers'Compensarion�nsu�ance, �bA��� - . HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec.3800,Lab.C.) �- �_eie(aEv.iOiSi) -� � � - - � cy
F❑olicy No. Company . . � � �O t'�'� �/ .
Certife c�op��iereby furnished: e un r}4824 COUNTY OF LOS ANGELES JOE$ 111I BUILDING AND SAFETY P�� 4
� Cert�Ged copy is filed wtth rhe covmy building inspeo- FOR APPLICANT TO FILL IN BUi�oiNG
tion department. � (PRINT OR TYPE ONLY) , ADDRE55
Date-7�—�APPlicant LOCALITY
NO. TYPE OF APFIIANCE OR EQUIGMENT � FEE
CERTIFICATE OF E%EMPTION M WORKERS' � NEnREST
COMPENSATION IN$ RANCE CROSS Si.
(Th��sadton noad nof bo camplated if ihe work involvod by ABSORPTION UNIT,BTU - OISfRICT NO. FROCFSSED BY �
� the permk Is►or ona hundred dollars(5100)or less.) AIR HANDIING UNIT,CFM a. �L�
I tertify Ihat in 1he performonte of the work for which this .
permit is issued,1 shall not employ any person in any manner
so as io become subject to the Workers'Compensplion lows. . gOILFR,BTU ApPROVAt$ DAiE INSPEGTO4"5 SIGN4TURE --
Dale APPlitont � � - - COMPRESSOR,BTU ROUGH ��f
NOTICE TO APPLICANT: If, afler moking Ihis Certificote of VENTitATiON SYSTEM � FINAL .
. EKemption, you should become subjecf �o the Workers' .
Compensalion provisions of fhe La6or Code,you must foAh- EVAPORATIVE[OOLER � � VALIDATION
wilh comply wilh s�th �rovii�ons or �his permit sholl be . �
deemed revoked. � - � FURNACE: FAU GRAVITY .
LICENSED CONTRACiORS DECLARATION� ROOa —� . .
I hereby alfirm thar I om licensed under provisions of Chaprer 9 SUS�ENDED UNiT_
NEA7FR: Wa��
'(commencing wilh Section 7000)of Division 3 of Ihe Business }
and Profe3sions Code,ond my license is in fuil forte and effect. � b ' �
.. License Number � Q§ggAg Lia Class e_�8 — , - {,�,�
Conrracror IrvineS4est Date 7-23—£37 a
O
❑ I am exemp�under Set. W
Plan check fee a
B.BP.C.for ihis reason� � H
PERMIT ISSUING FEE S - Z
�ore:
Signature TOTAL FEE_ — '
:1153A
� OWNER-BUIIDER DECLARATION . � PLAN CHFCK aaeuC.4Ni , .
I hereby affirm that I am exempt from ihe ControUor's Litense � a • • • �cR,
law for the following reason(Section 7031.5, Business and NAME . � o o J�O O �
Professions Codc�: ' � � .
❑ I,os owner of the properly, or my employees wilh ADDRESS - � • s •��Q(��,
wages as their sole campensalion,will do Ihe work and CITY - TEL.NO.
ihe structure is no1 intended or offered for sole�Sedion Q�.Q J—Pi 1
7044,8usiness and Proiessions Code). . -- - - �
OWNER
❑ I,os owner o!the propeny;om exclusively conrrocring �
wiih Ircensed mnrracrors to consrruct rhe project(Seo� �''A�� - - � , '
� tion 7044,Business and Professions Code). Aooee55 .
� CONSTRUCTION IENDING AGENCY ��TYNe�u ort Beach 92600 TE�'r`�P714) 833-3600 '
I heieby affirm thal there is a tonstr�ction lending agency for ►
the performance of the work for which this permit is iswed CONTRnCfOR" - - � -
(Sec.3097,Civ.C.). . . �._ _ _ .
� - - ADDRESS�. . . .. . . . . . . . . . � .
lender's Nome g.;,}}
- . . LITV . TEL NO �
Lender's Address — � � � � � � �
STATE UC.
I certify that I have reod�his applitolion and stale thot Ihe LICENSE NO. � CLA55 � . - .- .
above information is correct.I agree 10 comply wiih all County � � �
o�dinances and Slale laws relalinq 10 building cons�rutfion, � ,
and hereby authorize represenlatives of this Coonty to eMer � � - � -� - - '� - - �� �� � � � ' �- � � �-
upon the above•mentioned property for inspectton purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig �re of APPlicon�or Agen� Daie . . . . . � . . .- . ..
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