HomeMy WebLinkAbout1154A WORKERS'COMPENSATIDN DECLARATION \ yL�S�� �
I hereby oifirm thal I have a certifica�e of consent to self APPLICATION'FOR PERMIT
insure,or o certifitote of Wo�keri Compensarion Insuronte, �dA364c HEATING - VENTILATING • AIR CONDITIONING
or a certifted copy thereof(Sec.3800,-Lab.C.) CE-B18(REV.10/81� - �
O�Y Na 1021516 Company State Fund � , �.��p
Certig{ied copy is hereby furnhhed. TR# 44824 COUN7Y OF LO$ANGELES JOB� 1111 BUILDING AND SAFETY PH'� 4
� Cerlified copy is filed wi�h the coumy boilding insper FOR APPLICANT TO FILL IN sunow�
1i0n depOftmenl. (PRINT OR TVPE ONLY) � ADDRESS F ,.
Dote �-23-87 APPlicanl LOCAL�TY
NO: TYPE OF APPLIANCE OR EOUIPMENT FEE
CERTIFICATE OF EXEMPTION OM WORKERS' nIEAREST
COMPENSAiION INSURANCE CRO55 ST. �
(This sacifon noad nof b�compl�f��l if fhe worR Involvad by ABSORPTION UNIT,BTU DISIRi�i NO. ' PROCESSED BY
tha parmff is(or ona hundrad dollars(SI00)or lacs.) � � �
I certi(y Ihat in the performan[e of the work for which this . � A�R HANDLING UNIT,CFM
permit is issued,I Shall not employ any person in any manner
- so os�o become subject�o rhe Workers'Compensolion�ows. BOILER,9TU qppqpyp�5 DATE INSPECTOR'S SIGNATURE -
Date 'ePP���a�� - . 1 COMPRESSOR,BTU ROUGH
NOTICE TO A7PLICANT: If, after making this Ce�lificate of VENTILATION SYSTEM � FINAt
Exemplion, you shou�d become subject to the Workers'
� Compensation p�ovisions of the Labor Code,you most fonh- EVAPORATivE COOtEe VALIDATION
with [omply wilh such provisions or Ihis permit sholl 6e �
deemed�evoked.� ' ' FURNACE: FAU�GRAVITY � �
IICENSED CONTRACTORS DECLARATION ], FIOOR eiU �
I hereby alfirm�hol�am licensed under provisions of Chapter 9 SuSaeN�ED UNiT_ � -
�(commencing with Section 7000)of Division 3 of the Business HEATER: WALL �
and Professions Code,and my license is in foll force and effecf. � 4 �
468'009 � � O
�license Number Lia Class C-2� - � y
► a
Irvineti7est 7-23-ti7 Q
Contmtlor po1e - ' � .
F
❑ V
I om exempt under Sec.
Plan check fee • ?1 1 5 4 A a
� 8.8P.C.for Ihis reason� � � �n
� PERMIT ISSUING FEE 5 - �
�ale: � �• • i • •8
5gnatu�e TOTAL FEE pp � e •����
OWNER-BUILDER DECLARA710N PLAN CHECK APFUCANT - ��s ����i O x �
� I hereby affirm ihat I am exempr from�he Conlracror's License . � 0&�3_8�"
law(or Ihe foliowing reoson($eUion 7031.5, 8osiness and NRME - . �
Professions Code): �
❑ I, as owner of�Ihe properfy, ar my employees with A�ORES$ .
wages es their sole rompensatien,will do the work and �
the structore is not inrended or offered for sale(Setiion CiTY TEt.N0. .
7044,B�siness and Professions Code).. -� , �
owNea SJilliam L on Comoanv
❑ I,as owner oi the property,am ezdusively coNracting . �
with licensed comrac+ors ro construd fhe projetl(Seo- �`''A�t �- � �� �-�
. lion 70d0,Business a�d Pr'ofessions Code). ' ADDRESS 19 CO: OT'd'tC' Plaza
CONSTRUCTION LENDING AGENCY CITYj]euvPO�t BEdCh 92660 TE�-�ef14� 833=3600
I heieby affirm�ho��here is a consfruction lending agency for
tha performance of ihA work for which Ihis permit is issued� �ONTRACTO - - � --�� ,
(Sec.3097.Civ.C.). - . _.. . .... . . . . .
AD�RESS . . _ .. . . ... . .... .._. ._ _� . � �"� �
� Lender's Name � -�-
°TYOran e Ca 92665 TEL.N 714 � -
' Lender'sAddress - �- � .
I certii that I have read lhis a lication and slo�e 1ha1 Ihe . STATE LIC. -
Y PP uceNse No. 468609 CLA55�C-ZO - - ---- �� ����.- � �� �� � . .
above informotion is mrred.I agree lo compiy wilh all Counfy � - �- �
ordinances and State laws relating to building mnstruction, _. � "
and hereby ooihorize representatives of rhis Couniy to eNer� � - � � � ��� - - - " � � � � '- - '- - � .
upon the obove-mennoned property for inspectton purposes: SEE REVERSE FOR EXPLANATORY LANGUAGE ._
�_�3_R7 _
no�ure of Apph<ant or Agent Da�e . . . � . . . ' �_ . .... . . . . . . . ..
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