HomeMy WebLinkAbout1151A WORKERS'COMPENSATION DECLARATION AppI.ICATION FOR PERMIT �
I hereby offirm tha� I have a certificate af consent to self
insure,or a certificme of Worke.s'Compensaron Insurance, ��3�� HEATING - VENTILATING - AIR CONDITIONING
or o certified copy thereof(Sec.3800,Lab.C.) CE-818(REV.10/81� �rI i
O�Y No. IO21516 Company S'tate FllIId (.(�f'i'�
Certified copy is hereby furnished. TR# 44824 COUNTY OF L05 ANGELES JOB�` 1111 BUILDING AND SAFETY PH'� 4
� Certified copy is filed wi�h ihe coun�y 6uilding inspec- FOR APPLICANT TO FILL IN BU����NG �
tion department. ADDRESS 20707 East Mill Lane
(PRINT OR TYPE ONtY)
pa�e 7-23-87 qPP���p�� ����TY Diamond Bar
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION M WORKERS' NE4RE5T
� COMPENSATION INSURANCE CR055 SL
(Thia�ocfion naod not bo eomplo�od if fba work inwlvod by A8`ARPTION UNIT,6TU msTe�a No PROCFSSED 9Y
the pormil is lor ona handrod do�lon(5100)or less.) qiR HANDLING UNIT,CfM � ��^y� / , �
1 certify.that in the performance af.the work for which�his / � L VlJ
permit is Issued,1 shall not employ any person in ony manner gpILER,BTII
so as to become so6jec�to ihe Workeri Compensofion Laws. qvvaOvas onTe INSPECiOR'S SIGNAiURE
Date App�iconf 1 COMPRESSOR,BTU ].O OO ROUGH LN..
NOTICE TO APPLICANT: If, oftar moking this Certifica�e of VENTItATION SYSTEM FiNAI �
Exemption, you sho�id become subject to the Workers'
Compensation provisions of the tabor Code,you must forih- EVAPORAT�vE COOLER VALIDATION
with comply with such provisions or this permit sholl be
deemed revoked. - FURNACE: FAU_X_GRAYITY �
LICENSEO CONTRACTORS�ECLARATION FLOOR BTU 10 �O
I hereby affirm thol 1 am Ncensed under p�ovisions of Chapler 9 HEA7ER: SUSPEN�ED UNIT, -
�(commencirg with Section 7000)of pivision 3 of the Business � �'�'A�� �
and Rofessions Code,and my license is in fuil torce and effect Q �n � �
dHA6�9 , �
License Number lic.Class �-20 ► y
Irvine�9est 7-23-87 °t
Conrrocror Date O
❑ I am exempi under Sec _� � S� ,q �
Plan check fee a
B.BP.C.for fhis reason �� • • ° •p Z
PERMIT ISSUING FEE; 10 SQ
Daie:
Signature TOTAL FEE (� i � .':��;
OWNER-BUILDER DECLARATION PLAN CHECK APMICANT � � �, � ;. c�r-.��.r.
I hereby affirm that I am ezempt from+he Contracror's License , �� ��--�' `�"
Low for Ihe following reason(Section 7031.5, Business and NAME �
Professions Code):
U'c�J—�7
❑ 1, as owner of 7he properfy, or my employees with ADDRE55 .
wages os�heir sole compensation,will do�he work and
the strutture is not inlended or offered for sale�Section CiTY TEt.NO. , �
7044,Business and Professions Code).
❑ OWNER 47illiam L on Com an .
1,as owner of the property,om exclusively contracting y
with licensed coNractors to consiroc�the project(5ec- �"�A��
tion 7044,Business ond Professions Code). ' A�RE55 19 Corporate Plaza .
CON57RUCTION LENDING AGENCY arr Newport Beach 92660TE�.N�.714) 833-3600
I hereby affirm ihat there is o construdion landing ogency for �
the performance of ihe work Ior which�his permit is issuad CONTRACTOR �
(Sec.3097,Civ.C.). .
ADDRESS
Lender's Nama e•
�iTY oran e Ca 92665 7EL NO.�714� 921-080
lender's Address
I certify thpt I hove read this application and slote ffiaf the iicerise No. 468609 C ASS C—Z�
a6ove information is torrett.I agree lo comply wi�h all County
ordinonces ond State laws relating ro building construd�on,
and hereby au�horize representotives of this County to emer �
up n the a6o�e-menfioned property for inspection purposes. SEE REVERSE FOR EXPIANATORY LANGLIAGE
��� 7-93—R7 . .
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