HomeMy WebLinkAbout1175A (5) wuKRtKS'CUMPENSATIONDECLARATION qpp�{CATION FOR PERMIT �
I hereby of(km that I have a certificaie of consent ro eelf
insure,or a ce�iifica�e of Workers'Compensation Insurance, HEATING - VENiiLATING - AIR CONDITIONING
or a certiiied copy�hereo((Sec.3800,Lob.C.� . �6A36eC '
� CE-B18IREV.10/8I) - � - � ' - - � /'� �/�/ ,
P❑olky No. 1(191 51 Fi Company Rtate Fund ` � � �-(J '��
Cert�fied mpy is hereby furnished. TR$ 44824 COUNTY OF LOS ANGELES JOS° 1111 BUILDING AND SAFETY pH# 4
� Cert�4ed copy ts filed with the county building inspec- _ FOR APPLICANT TO FILL IN euitoiNG
fion deporfinenf. • (PRiNT OR TVPE ONIY� ADDRESS .
Daie 7-33-�7 APPlicanf Locnu7Y
NO. TYPE OF APPLIANCE OR EQVIPMENT � FEE
CERTIFICATE OF EXEMFTION M WORKERS' NEAaESi �
� � COMPENSATION INSURANCE . Ck055 5T.
(Thif s�cfton need nof ba eomplated if}he werk Involved by � ABSORPTION UNIT,BTU � oistuitr rvo. acocessro er
fh�pormil f�for one hundred dollars(5100)or lass.) � ry,�, �
I ceriify Ihai in the per(ormance o(fhe work for which this . AIR HANDLING UNIT,CFM � ���1 �
/
permif is issued,I shol)nol employ ony person in any manner � � _
� So ds lo betome subje[t fo Ihe Workers'Compensolion Lpws. gOItER,BTU ApPROVAIS onrE INSGECTOR'S SIGNATpRE
Date ePP���p�t � COMPRESSOR,BTU ROUGH ��,
� NOTICE TO APPLICANT: If, ofter making this Cer�ificote of VfNiRATION SYSIEM FiNnl s '
Exemption, you should� become subjeU �o ihe Workeri
Compensotian provisions oi Ihe Labor Code,you musl forth- EVAPORATIVE COO(ER � VALIDATION -
with comply with such provisions or ihis permil shall be �
deemed revoked. FURNACE; FAU_}F—GRAVIN .
LICENSED CONTRACTORS�ECIARATiON FLOOR BTU
I hereby a(firm Ihot I am licensed under provisions of Chapter 9 SUSPENOEo UNIi_.
'(commencing wilh Section 7000)of Division 3 of fhe Business - HEnTER: WA�� .
and Professions Code,and my license is in full force and eflect. �"
Q ( � °'
O
License Number� � ztlo�nP,n�_Lic Class ��0 - � , U
rvineSlest �7-23-87 �
Controcror I Daie � . �
❑ �-.
I om exempt under Sec. Plan Chetk fee `� � �'S� a
8.8P.C.for this reason� �
PERMIT ISSUING FEE$ 10 50 {�° • '• •B z
Date: . � ' •Q�'J Q
Signature TOTAL FEE • � •!!��;V�
� OWNER-BUILDER DECLARA710N PLAN CHECK APPIICANT � U FS O��S 7
I hereby offirm�hat I am exempt from rhe Cantractor's Ltcense �
Low for�he following reoson(Section 7031.5,Business and Nnh�E . .
Professions Code�:
- ❑ I, as owner of Ihe property, or my employees wiih ADDRESS �
wages as iheir sole mmpensafion,will do Ihe work and � .
the struuurr is not imend>d cr offered for salo�Seciion CtTv TEL.NO. �
7044,Business and Profezsions Code). . � pyyNEe �,Tilliam Lyon Company
❑ I,as owner of rhe prope�ty,am exclusively conlro[fing MAi�
with licensed confroclors 10 conslruct the projecf(Sec- qDDRE55 19 Corporate Pld2@� ,
tion 7044,Bvsiness and Professions Code). � ,
CONSTRUCTION LENDING AGENCY � �� ��Ty N2WpOIt Beach 92660�� Nb714)��833-3600 � �
1 hereby pffirm thot fhere is a consiruction lending agency for , � , - -
the performonce of the work for whith�his permif is issued '� CONTRARORIrV1IICW0St�Htg & 111r � � � � � � �
. . ..... . .. _. . .. ... __.
ec.3097,Civ.C.). ��
., , ..,
nooeess 638 Southern Ave. -
_
Lender's Name
arv Orange Ca 92665 Te�.No.(714) 921-080 ._
Lender's Address
I certify�hal I have reod this applica�ion and state that ihe ilCeNse No.. 468609 . ciA55 C-20 � � ,
.. ...
obove information is correct.I ogree�o comply wi�h all Coonty _ '
ordinances and Stote laws relming�o building mnsiruction, � - - _ _ �
ond hereby authorize represen�otives oF this Coonty fo enter . . � � . . -- . � '" " � -
upon ihe a6ove•me ioned property for inspec�ion pu�poses. SEE REVERSE FOR EXPLANA70RY LANGUAGE
7-23-87
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