HomeMy WebLinkAbout1177A (5) WORKERS'COMPENSATIONDECLARATION APPL'CATION. FOR PERMIT �
I hereby aHirm tha�I have a certifitate of consent�o self
insure,or a certificate of workers'Compensation Insurante, 76A364C HEATING - VENTILATING - AIR CONDITIONING '
or a cerli(ied copy ihereof(Sec.�3800,Lob.-C.) - , .
CE-818(REV.10/81) . . .. . 'At��
Policy No. +no�z_P.,ai F Company StBte PUIId � � ��
❑ Certified topy is hereby fumished. TRn 44824 COUNTY OF LOS ANGELES JOII�"r 1111 BUILDING AND SAFETY pFi$ 4
� Certlf,ed capy is filed with ihe counry building inspec- - FOR APPLICANT TO FILL IN - - � BuiLDiNG
lion deportment. (artiNi OR TVPE ONLV) Aooaess 20735 East Mill Lane
Date��_Applicant LOCAUTY
NO. TYPE OF AP7LIANCE OR EOUI7MENT'- - � FEE
� CERTIFICATE OF EXEMPTION F M WORKERS' �� NEAREST '
� COMPENSATION INSURANCE � CROSS ST.
(Thlt sotfion naad not ba tompleled if fhe work involved by . ABSORPTION UNIT,BTU DISTRK�NO. PROCESSEO BY �
fhe pa'rmlt Is For ona hundrad dollars(5100)or less.) � `�� �
I cerrify fhm in the per(ormanca of ihe work for which Ihis A�R HANOIING UNIT,CFM -
� perml�ts issued,I sholl no�employ ony person in any manner
so as to betome subject to the Workers'Compensalion Laws. BOILER,BTU AVGROVA�S DA7E INSPECTOR'$$IGNATURE
Date �pplicant � _ COMPRESSOR,BTU ROUGH
NOTICE TO APPLICANT: If, after making ihis C@rlififdlB 9f VFNTILATION$YSTEM . FINAL (�� �
Exemption, you should become subject to the Workers'
Compensotion provisions of Ihe Lobor Code,you must forth• EVAPORATIVE COOIER VAL�DATION
with tomply with s�ch provisions or lhis permif shall be
deemed revoked. �� � FURNACE: FAU GRAVITY � �
� LICENSED CONTRACTORS DECLARATION FLOOR � �
- I hereby offirm thot I am licensed under provisions o�Chapler 9 SUSPENDED -UNii-_ .
'(commencing with Section 7000)of Division 3 of the Business HEATER: WA��
and Professians Code,and my license Is in full force end effe[t. - - �'
O 'f U p
License Number��.Lic.Class��_ '� . � � - - - - , V
neWest 7-23-II7 �
Conrrattor rrvl Dme . . . . . . O
❑ � F-
I om exempt under$ea - w
, Plan clieck fee a
B.SP.C.for ihis reason� � �
PERMIT ISSUING FEE S 10 50 �
Da�e:
Signa�u�e TOTAL FEE
OWNER-BUIlOER DECLARAiION � ttAN CHECK AGPtiCANT �� � 7.7 F
I hereby affirm�hat I am ezempf From the Comractor's License
Law for Ihe iollowing reoson(Section 7031.5, Business and NAME � � �:• • " •R .
Pro(essions Code�: � � � . '
AD�RE55 � ' '��1 O
❑ I,as owner of the properly, or my employees wilh . � �i�n
wages as tneii sole compensa�ion,will oo ine wark arid ���U�_��T
ihe structure is nol intended or oifered for sale(Settion CITY TEI.NO.
7044,Business and Proiessions Code�. . . � � .
� � � OWNER ���illian Lyon Company '
❑. I,as owner of the proPerty,am exclusively contiacting �
wilh licensed tonlroUors to conslrucf the projecf(Sec- DORESS 19 Corporate P1dZd � �
�ion 7044,Business and Professions Code). . .
CONSTRUCTION LENDING AGENCY � arv N2oto0Yt-BeaCh-92660TEt.N�.714)� 833-3600 -
I hereby affirm thal there is a tonsh�ction lending ogenty for � ,
ihe performance of the work fo�which�his permif is issVed � � �ONTRARORIrV1I12T4e5t I3�' & AlY
(Sec.3097,Civ.C.). � , - . .. . . . .
aooaess 638 Southern Ave. - �
lender's Name
. aTvprange Ca 92665 - TE�.No.(714) 921-0�0 _
lendei s Address ' ' . -
I certiiy that I have read ihis opplim�ion ond s�ale Ihot Ihe LICENSE NO.- �'6H6�9 �ASS C-20
above information is corred.I ogree�o comply with oll County . . _
ordinances ond State lows relaiing to building consfruc�ion, � ,
and hereby aulhorize represeNalives of this County�o enier : � . � � � � - -�-� � � � " " � . �
� on rhe obove-men�oned p�operiy for�nspecrion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
r ' 7-23-87
Si �ure of Applimm or Agen� . Dofe � - �� � �� � -� � � � � " �� �� � �' � - � � �
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