HomeMy WebLinkAbout1176A (5) � WORKERS'COMPENSATIONDECLARATION � APPLICATION- FOR PERMIT �
I hereby a(fnm thol I have a certifica�e of consent to self
insure,or a certifimle of Workers'Compensation i����a��e, �� � � - HEATING -�VENTILATING - AIR CONDITIONING - r�
or a certified copy thereof(Sec.3800,Lab.C.) 76A364C .
a CE-818(REV.10/81� . - .. . -- -� � ' �y,��/�
P❑olicyNo.�'+�y���Campany��.y��Tag . � .
Cerlified copy is hereby furnished. TR'-� 44824 COUNTY OF LOS ANGELES..JOBn 1111 BUILDING AND SAFETY PH$ 4
�/ Cert�led topy Iz filed wi�h the caunty building inspet- FOR APPLICANT TO FILL IN aU�LDING
T tiondepor}menf. (PRINTORTYPEONLY) ADDRESS Z0729 East t4i11 Lane
oaie 7-23-87 APPlicont � — � iocnurr Dianond Bar
NO. TYFE OF APPIIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION F M WORKERS' NEAREST
COMPENSATION INSURANCE . � . CROSS ST.
(Thls�aclion naad nof be complNad tf the work Invelvad by ABSORPTION UNIT,BTU OIS�RiC1 NO. vxOCESSED BY .
Ihv permi}Ia for one hondred dollars(SI00)or less.) �� /�� ��
- AIR HANDIiNG UNIT,CFM
I certify Ihot in the performance of the work for which thts �r�
permit is issued,I shall nat employ ony person in ony monner gpllER,B7U --
so as to become subject to the Workers'Compensation Laws. AvvaovaLs onTe INSPEROR'S SIGNATURE
Date � Applitan� � 1 COMPRESSOR,BTU 4$,OOO �.O OO ROUGH
NOTICE TO APPLICANT: If, after making this Cerlifimte of � VENTItAT�ON SYSTEM FlNnI �
Exemption, yo� should become subjecr to the Workers'
Compensmion provisions of the labor Code,you muzt forih- Ev.4POZATwE COOtER VALIDA7ION
with comply with s�ch provi3ions or Ihis permit sholl br.
deemed revoked. � � - FURNACE: FnU X Genvitt '� '
- LICENSED CONTRACTORS DECLARATION. . 1 FtOOR eTU 90�000 10 00 '
I hereby affirm that I am licensed under provisions of Chapler 9 HEATER: SUSPFNDED UNIT_ , _
'(commencing with Section 7000)of Divizion 3 of ihe Business WA��- �
and Professions Code,and my license is in full force and effect. � - - a
TS & LETS 5� O
License Nvmbe. 468609 lic.Class C—z� �- -� � - � � � V
Irvine�7est 7-23-87 "1 1 7..h A O
Controttor Date - - -
� I am exempt onder Sec .. . _ . ���� , , �� �
Plan check fee °�
�
B.BP.C.fo�this reason' PERMIT ISSUING FEE S 10 50 f •'•5 i 0 0 Z
Date:
Signa�ure TOiAL FEE S:S- UV ' ' 'S�`n'�'
. OWNER•BUIIpER�ECLARATION � PLnN CHeCK nPPIiCAn1r � O CS O 3—�3�I
1 hereby affirm ihal I am ezempt from the Contractor's Litense � � .
Low for Ihe following reason(Section 7031.5,Business and NAR�E - - -
Professions Code): - � � - �
❑ I,•as owner o(the properry, or my employees with' ADDRESS �
wages as�heir sole compensafian,will do the work and ��n, TFL.NO. -
�he struU�re is not inlended or offe�ed for sale(Sec�ion
7044,.Business end Professions Code). .. �
� OWNER S,7illiam Lyon Company � . �
❑ I,as owner of the property,am exclusively conirocting
� with licensed contraUors lo mnsfrud the projed(Set- DDRESS 19 COrDOIdtC Plaza -
tion 7044,Bvsiness and Professions Code�. -
CONSTRUCTION IENDING AGENCY � CiTY NeWPOrt Beach 92660rei.N�714)�833-3600
I hereby affirm that ihere is a tonsf�otfion lending ogency for ,
Ihe performance of 1he work for which Ihis pe�mil is issued CONTRACTOR - -
. (Sec.3097,Civ.C.). Irvine�9est Ht & Aix - . . . _ .. . _ . _ . ..
- n�oaess 638 Southern Ave:
Lender's Name
lender's Add�ess ��TM Orange Ca 92665 TEL.NO(714) 921-080
� STATE LIC. _
I certify�ho�I hove read this applita�ion and state that the . IiCeNSE NO. 468609 CLa55 -.C 20 ,_ _ ,__ _ ,
above iniormation is correct.I ogree to compty with all Coonty . - � �
ordinonces and State laws rela�ing to bvilding tonstruction, . _ _ _ __ _ , _ . . . ... . . .... . . _ �
and hereby authorize represema�ives of this County to enter
u on ihe obove.mentioned proper�y for inspecrion poFposes. 'SEE REVERSE FOR EXPLANATORY LANGUAGE . .. _ .
_ �C.. ']—��—R7 . .
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