HomeMy WebLinkAbout1174A (5) WORKERS'COMPENSATION�ECIARATION APP`tCATION FOR PERMIT I'
I hereby oif'rrm ihat I have a cerlificote of cansen�to self
�nsura,or a ceriiii��e of workers'Compensa�ion Insorance, jy1364c - HEATING - VENTILATING - AIR CONDITIONING 2S
or o tertified cCpy ereof(Sec.3800,Lab.�.) -CE-818(REV.10/81 j � . �
acy No. 1021516 Compony State r^und /_Gt��V
Cenified copy is he�eby fomished. TR',� 44824 COUNTY OF LOS ANGELES.JOB$ 1111 BUILDING AND SAFETY PH'� 4
n Cert�ied copy is filed wiih�he tounty building inspec- � � � FOR APPLICANT TO FILL IN BUitDING �
"t' tiondeporiment. L��_ _ � . ADDRESS 20717 East t4i11 Lane
?' �f (PRIMT OR TYPE OMLYJ
Dote �-?�-&'7 Appliconr ,�f`l� LOCAIItv Diai;iond Ba:
. CERTIFICATE OF EXEMPTION F WORKERS' NO. TYPE OF APPl1AN[E OR EQUIPMENT � . FEE NEAREST
� COMPENSATION INSU ANCE CROSS St. .
(Thls setl(on naed nol ba tomplo}od if the work involved by ABSORPTION UNIT,BTU DISiRi�T NO. YRp�E55ED BY
the permil Is(or one hundrad dollars(5100)or less.) �y�
I certify ihat in ihe performance of�he work for which this AIR HAN�LING UNIT,CFM � � /�p C{�
permit is issued,I shall nat employ any person in ony manner
so os to become subject ro ihe Workeri Compensation lows. � BOiIER,BTU APPROVAL$ D/.tE INSDECTOR'S SIGNA74RE _
Date Appliconl � 1 COMPRESSOR,BTU 4II.00O ZO OO ROUGH .
�NOTICE TO APPLICANT: If,-afte� making ihis Certificate of VENTitATIONSYSTEM FINAL '�j
Ezemption, you should 6ecome sub�ect io the Workeri
Compensatiori provisions oI the lobor Code,you mus�fcr�h- evAvo2niive cootert VALIDATION
with comply with wch provisions or this permir shall be .
deemedrevoked. � . FURNACE: FAU X Gqqy R �
�- IICENSED CONTRACTORS DECLARATION 1 FIOOR eiU yU•��- 10 00
I hereby affirm Ihof I am litensed under provisions of Chopter9 SUSPENDED UNIT_ � .�
HEATER; . WA�� .
�(commencing with Sec�ion 7000)of Division 3 of ihe Bosiness }
and Proiessions Code,and my license is in foll iorce ond effecL� Q
N TS & OULETS S'a p
License Number ��`���9 Lic.Class C-20 - -- - _ � ► t1
IrvineSaest � 7-23-87 a
.Contrador pote d
H
❑ I am exempt under Sec. �- . .. , . �� ��7,tl A w
Plan check fee' �{ • • • • .B y
8.8P.C.for�his reason� . �
PERMIT ISSUING FEE S 10 50 � .'e�a�n ?
Dare:
Signature TOTAL FEE ' • 5����O-
OWNER-BUILDER DECLARATIDN aAN CHECK A7PLtCnM .
I he�eby affirm ihat I am exempt from�he Contrador's License - � .
law for the following reason(Sec�ion 7031.5,Business and NAME .
. Professions Code�: -
� ADDRESS - �i�
I, as owner of the preperty, or.my employees with �J-�j']
�woges as their sole tompensalion,wili do the work and � • �
- the shoctpre is not iNended or olfered for sole(Settion CITV TEL.NO.
7044,B�siness and Professions Code). . � � .
owNea William Lyon Company
❑ 1,os owner of the properfy,am exdusively comrocting �„�Att- ��� � � �
wilh licensed contracfors to conskuct the p�ojett(Sec- ADORE55 19 Corporate Plaza �
tion 7044,Business and Professions CodeJ. ' . '
CONSTR�CTION LENDING AGENCY aTr Newport Beach 92660;¢i.Nd714) 833-360 , �
I hereby oflirm�hat ihere is a tonsiruc�ion lending agency for ,
ihe performonce of the work for whith this permit is issued COMRA�TOR jYV1II2WL'ut Ht & A1S
(Sec.3097,Civ.C.). . . . --. ._... -- - -
- AD�RE55 G38�Southern nve. � �� � �� �- - - �� - � � � �
lender's Nome
tender's Address c�Tv Orange Ca 92665 TEL NO.(7�.�) 921-08 0. _ . .
I cerlify that I have read this application and sta�e Ihat ihe iicENse No. 468609 �ASS e-20
above informeiion is corretl.I agree to comply with all Couny �
ordinonces ond Stale laws relo�inq to building tonstruction, '
ond hereby authorize represematives af this Coonty to enter . - � � �� � � " - � "� - "
upon the above-men�ioned property for inspection purposes. . -SFE REVERSE FOR EXPLANATORY LANGUAGE
�Ll,�.� 7-23-87 _. _
5 arore of Applimnt or Agenr � Dote . � . - - . - .. . . . . . .. . . . . . � � �.
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