HomeMy WebLinkAbout1173A WORKERS'COMPENSATION DECLARATION � �
I hereby affirm Ihof I have a certificafe of�on5e�,��o,e�r . APPLICATION FOR PERMIT
insure,or o cerrifimio of Wwkers'Compensmion Insuronce, i��6ec •HEATING - VENTILATING - AIR CONDITIONING
or a cer�ified copy thereo((Sec.3800,Lab.C.) �
. .CE.818(REV.10/Bl) . . .- .... . �����
P❑olicy No.-1(121 51 f, Compony State Fund - '
Certified copy is hereby furnished. TR$ 44824 COUNTY OF LOS ANGELES JOB� 1111 'BUILDING AND SAFETY PI3n 4
� CertXied topy is filed with�he counry building inspec- POR APPLICANT TO FILL IN euitDiNG
tion deparfinent. �PRIM OR TYPE ONLY� AODRESS
Da�e �—��=g� ApplicoM L LOCALITY Diamond Sar
� NO. TVPE OF APP�IANCE OR E�UIPMENT � - FEE
CERTIFICATE OF EXEMPTION M WORKERS' NEAREST
COMPENSATION INSURANCE �CRO555T. �
(ThI�tettion naad no}ba complefad 1(the work Involvad by ABSORPTION UNIT,BTU DiS�Ri�i NO. PROCESSED BY
fhe permit Is for ene handrad dollars(SIDO)or less.) AIR HANDLING UNIT,CFM � - � �rn �j�
I cerlify thot in ihe performance of Ihe work(or which this�
permit is iss�ed,I shall not employ any person in any manner BOiLER,BiU
so as to betome sobjed to the Workeri Compensetion Laws. � nwaovnts �qTE ' INS�FCTOR'S S�GNATVRE --
DCfe APPIiCont COMFI2ESSOR,BTU I,O OO ROUGH � Ltii`
NOTICE TO APPLICANT: If, ofter making �his Certifitote of VENTIIATION SYSTEM FINAL
Exemp�ion, you should 6etome subjecl lo the Workers'
Compensolion provislons of Ihe lobor Code,you must forlh- �/qppRATIVE COOLER VALIDATION
with comply wilh such provisions-or this pe�mit shall be �
deemed revoked. � FUaNaCE: FaU�_GRAVitY ��
� LICENSED CONTRACTORS DECLARATION ftOOR B7U 10 OO �
I hereby aHi�m�hat I om licensed under provisions of Chap�er 9 � HEATER: SUSPEn7�ED UNIT_ - ' .
'�commenting with Section 7000)of Division 3 oi the Business w/+«
�and Professions Code,and my license iz in full force and effect. - Y
Q a
License Number 468689 Lic Clasi s—aA . , � _ O
U
Contracfor Trvifl0S�E5t Dote �-23'3� � -- �
O
u❑ I am ezempt under Sec. - � � W
Plcn check fee a.
B.BP.C.for this reoson� en
Date:
PERMIT ISSUING FEE S 10 50 Z
Signa�ure TOTAL FEE Q �7
�� OWNER-BUILDER DECLARATION PLAN CHECK AVPLICAM ��.�,� �•J A.
I hereby affirm tha�I am exempt from ihe CoMrador's License � (j e • . • •�?
� Law for the following reason(Section 7Q31.5, Business and NAME � � . , � • •(���O
Professions Code): � � . .
❑ I, os owner of the property, or my employees with ADDRESS • ° °��Q�� ,
wages as iheir sole compensa�ion,will do the work and GITY iE�.NO. � ��r;�—�7
�he siruc�ure is not in�ended or offered for sale(Section .
7044,Business and Professions Code). � � .
OWNER William L on Com an �
❑ I,as owner af Ihe property,om exdosively contracting P Y
� with licensed conlracton to conslruct ihe project(Sec- ��� � � - �
tion 7044,Bwiness and Professions Code). . /+ooRE55 19 COY orate Pld2d
CONSTRUCTION IENDING AGENCY � ��n' Newport IIeach 9266QFi.No(714) £333-360
I hereby affirm that there is a constructian lending ogency for ► �
the performance of the work for which ihis permit is issued � COMRACTOR � - �
(Sec 3097.Civ.C.J. . _ . _ . . ' . - . ... .
._.
ADDRF55 � - - �' - .
Lender's Name� ' il AVO. - ... ... . . ....... .". `_-.� � ..� .
Lender's Address C�TY Oran e Ca 92665 rE�.No.(714) 921-08 0-------
'I certify Ihat I have read this applicotion.and s�ate that�he iicerise No. 468609 C A55 - C-20
. ... . . .:... ... . ._ . . .
above Informotion is correct.I ogree to comply wiih all County � � �� " - - .
ordinonces and$fote lows relaling to building construction, � � � �
and hereby authorize represenlatives of this Counfy Io enter � � �� ��- � - � � � � �--�-- " - �
up n the above-menti 'd property ior inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE .
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