HomeMy WebLinkAbout1158A (5) WORKERS•�oMPENSAT�oNOE«ARAT�oN � . �APPLICATION FOR PERMIT �
I hereby af(Km thot I hove a certificate of consenl to self
insure,or a certificata of Workers'comPe�saro�i„s�,a„�e,. ,bA3�ac . HEATING - VENTILATING - AIR CONDITIONING
�or a cerlified mpy Ihereof(Sec.3800,Lob.C.) -� �_g�8(REV.10/81)' �- -- - � --- �— � .
Ata`e Funn ' �0 f#`��
�Policy No. Company COUNTY OF LOS ANGELES u eUIIDING AND SAFETY u
Ce�lifi erebyiurnished. � . TR$ 44824 . JOBn 1111 PHn 4 �
� Cer��ed copy is filed wi�h the tovnty boilding inspeo- FOR APPLICANT TO FILL IN Bun�iNc
tion departmen�. � nDoeeSS
. (PRINT OR NPE ONtY)
Date��—��—g'] qppl�co�r ��'��TY Diamond Bar
NO. TYPE OF APPUANCE OR EQUIPMENT � . �FEE
CERTIFICATE OF EXEMP710N M WORKERS' NEARESi �
COMPENSATION INS RANCE CRO55 SL �
(Thls tacfion nood no}ba complefad 1I}ha work(nvelved 6y ABSORPTION UNIT,BTU Oi51RiC7 NO. PRpCESSED 6Y
Ihe permit Is for one hundred dollars(SI00)ar lacs.) qIR HANDLING UNIT,CFM �a �^ �
. I cer�ify�ha�in the performance of�he work for which this / I�
_ permi�is issued,1 shall not employ any person in any monner _
so as to become s�bject to the Workers'Compensotion Laws. b�ILER,B7U qvFRpYALS DAiE INSPECTOR'S SIGNATURE
Date Applicont COMPRESSOR,BTU ROVGH �
NOTICE TO APPLICANT: If, after making Ihis Certiiim�e of VENTILATION SYSTEM - FINAL
Exemption, you shoold betome subjed to 1he Workers: .
Compensoiion provisions of rhe lobor Code,y0u musl�Or�h• EVAPCRATIVE COCIER VALIDATION �
with mmply wilh soch provisions or this pe�mit shall be .
deemed revoked. � FURNACE: FAU—y GRAVITY�� �
IICENSED CONTRACTORS DECLARATION FIOOR BTU �
I hereby afiirm that I om licensed under provisions of Chop�er 9 - . SUSaENOED VnliT_ -
`(commencing wilh$ection 7000)of DiviSion 3 oi�he Business HEATER: WA��
� and Professions Code,and my licensa iz in full force and efiecl; . - �"
s a a
O
license Nomber 4686e�_Lit.Class e—�g - - , V
Conrroctor Irvinei4est �
�a,a �—zs—s� s 1 1 5 8 A �
❑ I am ezempl under Set. " - , _ � ' uVi
Plan check fee # • •� a
8.8P.C.for this reason'
Date: PERMIT ISSUING FEE S � • •7�O O, �
Signature � TOTAL FEE 0 • • •5.ri 0�_
OWNER-BUILDER DKLARATION � PInN CNECK avaIICANi O P4 O�J—a 7
� I hereby affirm that I am esempt from the ContraUor's license- � � ,
Low for the following reason(SeUion 7031.5,Business and NAME �
Professions"CodeJ: , � - .
❑ I, as owner oi Ihe properly, or my employees wilh /+DDRESS
woges as their sole tompensotion,will do the work ond
. the structure is not in�ended or oifered for sale(Seclion CiTY TEL.NO. .
7044,Bosiness and Professions Code). - .
OWNER
❑ I,as owner of Iha property,om exclu:ively conhacling ld7tt L On Coin an
with litensed convactors to mnstruct the project(Sec-� �"�'41L -
fion 70dG,Business and Professions Code). ADDRESS 1 COL orate Plaza
CONSTRUCTION LENDING AGENCY � - C�rv N@W ort Beach 92660T��•NQ�714)- 833-360
I hereby affirm Ihot there is a construction lending agency tor ,
�he performonte of the work fo�which this permit i5 i55ue(J" ' COMRACTOR � - " ' '
. (Sec.3097.Civ.C.). . . . . ---� . . .
� ADDRE55 � �' - ' " - ' � - - .
lendei s Name
crtr TEL.NO. 714 921-08
Lender's Addreu � �
I ceitif �hat I have read ihis a limtion ond s�o1e thal ihe STATE uC.
y pp UCENSENO. QG$GO9 - �CLASS C-20 �-- � -� - . . _ _ -
� a6ove informalion is conect.I agree lo tomply with pll County
. ordinances and State laws reloting to 6uilding construction, ,. � �
and hereby authorize represenfofives of lhis County to enter . �� "
upon ihe abo�e-mentioned properry ior inspectian purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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