HomeMy WebLinkAbout1178A WORKERs�aMPENSAT�oNOE��ARAr�oN �� APPLICATION �FOR PERMIT � � � �
I hereby offirm tha�I have a certi(icate of consent�o self
insure,or a tertificma oi Workers'Compensa�ion lnsuronce, . �bA��� - HEATING - VENTILATING - AIR CONDITIONING
or a cerfiiied copy hereof(Sec.3800,lab:C.) -
CE-818(REV.IOi81�. . . . .—...._ ....._. - ��)'/ .
Policy No. i n��an��si u Company�a-��e v�,�_....7 � Yr
❑ Certif(ed capy is here6y f�rnished. TR,€ 44824 COUNTY OF LOS ANGELES J0B# 1111 BUILDING AND SAFETY PHn 4
� Cert�ed copy is filed with the county 6uilding inspec- � FOR APPLICANT TO FILL IN -- -- eVnowG
lion department. ' (PRINT OR TYPE ON�Y) ADDRESS
pote�}_Applicanl LOCAIITY �
NO. NPE OF APPIIANCE OR EQU�PMEM FFE
CERTIFICATE OF EXEMPTION F OM WORKERS' NEAREST �
COMPENSATION INSURANCE � CRO55 ST. -
(Thts seclton need nol be completed iF}he work involved by A850RPTION UNIT,BTU Disir+iCt rv0. PROCESSEo Br .
the permlf ts for one hundred dollors(5100)ar lass.) ' � ✓1M , �r-�'
I tertify fhat in the performance of ihe work for which�his AIR HANDLING UNIT,CFM //! (/V
. permit is issued,I sholl not employ ony person in any manner gOILER,BTU
so as l0 6emme subjeU to the Workers'Compensafion laws. nveaovni5 DAIF INSRCTOR'S SIGNATU4f _
Da�e ApPlicant � � COMPRESSOR,BTU ROUGH '�.�
� NOTICE TO APPLICANT: If, ofter making this Certificate of VENTILATION SYSTEM FINAL �,�.+� ���
Ezemption, you should betoma subjecf to the Workers' -
� Compen<_otion provis�ons of the lobor Code,yw most forth- EVArORAnvE CootEe VALIDATION ,
with tomply with s�ch provisions or fhis permit sholl be
�deemed revoked. � - FURNACE FAU GRAVITY
, ❑CENSED CONTRACTORS DECLARATION � ' FLOOR �STU �
I hereby offirm that I om licensed vnder provisions of Chap�er�9 HEATER: SUS7ENDED � i_ , '
�(commenting with Sedion 7000)of Div�sion 3 of the Business WA0. • , .
and Professions Code,and my litense is in full force and effect. �- � � y
� �7 � ' �
License Nom6er n6E3609 Uc Class C-20- i . _ , � . V
Irvine[,test 7-23-87 O°
- ContraUor Date � � ��� � � �
ti
A �
O _ W
I am e.emp�unde�See. Plan check fee �� � �Q a
B.BP.C.fo�this reason� �
- PERMIT ISSUING FEE S 10 50 '�.� �.� '� z
Date:
TOTAL FEE y (� I s •(l 8.0 O
$ignature . , .
- OWNER-BUILDER DKLARATION � MAN CHECK AVPUCANT - • �ll�C csi
I hereby offirm that i om exempt from the Contractor's License � ��C�—.�J�
Low fo�the follOwing reason(Set�ion 7031.5,Business and NMAE
Professions Code): . - . � �
❑ �, as owner of Ihe property, or my employees wilh �+DDRE55 � - .
wages as their sole compensatian,will do the work and ��T� � TEL.NO. � �
�he structure is not iMended or of(ered for sale(Section
7044,Business and Professivns Code). -
OWNER �qilliam Lyon Conpany �
❑ I,os owner of ihe property,am exclusively contratting
wifh lice�sed mniroc�o�s to consfruct Ihe project(Sec- . DDRE55 19 Corporate Plaza��� � � �� .
tion 7044,Business and Professions Code). .
CONSTRUCTION LENDING�AGENCY - CINP12tvnOtt IIeach 92660hi,r,b714)-E333-3600 '
1 hereby affirm tho�there is o construction lending agency for
the performance of Ihe work for which this permit is iszued �ONTRACTO - � - "- -�� ��' ,
(Sec.3097,Civ.C.). . . �IrvineWest Ht & Air _. . .. , _ .. . _ .
� � ADDRE55-63H Southern Ave. � � � -� �� � � � � � � � � � � --
Lender's Nome
Lender's Address C�TY Ox'ange Ca-92665 rEi.No(714) �921-080 - � �� � - - . - .
I certify rha�I hove reod this opplimiion and state tho�the iicenise No. . 46£3609 Ct 55 -C-20 _ - �
.._ -_ __ .... ... . _ ..
o6ove information is correct.I ogree ro comply with all County .
ordinonces and Slate laws relating to building conttruction, - � , . � -
and hereby aulhorize representotives of this Counfy to enter -�- ��� �� � � �� � ��� �
upon the obove•me tioned property for inspec�ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE. _
L 7-93—R7 —. _.. _ .. .
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