HomeMy WebLinkAbout1160A WORKERS'COMPENSATIONDECLARATION AppLICATiON FOR PERMIT �
I here6y affkm fhal I have a certifica�e of consenl to self
�nsure,o.o canificaie of wo�kars'Compensotion i�5�,o��e, � HEATING - VENTILATING - AIR CONDITiONING
or a certi(ied copy thereof(Sec.3600,Lab.C.) ��+3�� �
CE•81B(REV.IO/ei)
O�y No, 1021516 �omPa�y State Funa Got��4
Certified copy is hereby f�rnislied. TR$ 44824 COUNTY OF LOS ANGELES JOB� 1111 BUILDING AND SAFETY pgg g
� Cert�ed topy is filed wiih the county building inspec- FOR APPLICANT TO FILL IN BURDING
. tion deportmenl. � ADDRE55 20742 East Mill Lane
/J� � (PRINT OR TYPE ONLY)
Da�e_ 7-23—ti7 applican�� -� ia'°uTv Dianond Bar
NO. TYPE OF APPLIANCE OR EQViPNENT iEE
CERTIFICATE OF EXEMPTION OM WORKERS' NEAREST '
COMPENSATION INSURANCE . CROSS 5T.
(Thl�sacflon noed no�6a tomple}ed if 1he work fnvolved by Ag50RPfION UNIT,BTU DtSLxKi No. . Pap�ES5E0 BY , .
tho permll If(or one hundred dollore(SI00)or less.) AIR HANDLING UNIT,CFM P> >'y-�_
�certify thot in ihe performance of�he work for which ihis � �� �r
permit is issued,I shall no�employ any person in any manner �
so as ro become subjeci to�he Workers'Compensa�ion Laws. . b�ILER,BTU APPROVAlS oate INSFECTORS SIGNATIIRE -
� Date oppliconl 1 COMPRESSOR,BTU LO OO ROUGH �1
NOTICE TO APPUCANT: If, affer mpking this Certificote of VENTILATIONSYSTEM iINAL �f �
� Exemption, you should become subject to the Workers'
Compensa�ion provisions of the lobor Code,you must forth- � ¢vnvOaaiive cOOtER � VALIDA710N '
with tomply wilh su�h provisions or lhis permit shall be
deemed re�oked.- � FURNACE: FAU_�_GRAVITY � � '
- . UCENSED CONTRACTORS DFCLARATION � FLOOR BTU
' I here6y af{irm fhat I am licensed under provisions of Chopfer 9 SUSDENDED UNIT—
�(commencing with Sectlon 7000)of Diwsion 3 of the'Business HEATER: � WA��
and R'o(essions Code,ond my license is in full force ond eifed. � -� �� }
0.
License Number 46R6(]�3 Lit.Class c-20 - . . . . , . .{,�.1
co���acro, IrvineiTest oare 7-23-87 �1 1 6.0 A �
❑ I om exempt under Sec. . ,. � � � w
Plan check fee It• • � • �8 N
B.&P.C.fo.rhis reasorc , PERMIT ISSUING FEE S f • •5.`x�O �
Da�e:
Sgnarure TOTAL PEE ,y' p0 • o •J;i Q��
� OWNER•BUIIDER DECLARATION PIAN GHECK APPIICANT
I hereby affirm thaf I am ezempt from ihe Controcior's License . � ���3—$7
law for the following reoson(Section 703I.5,Business ond NAME
Professiom Code): � . � �-- , ,
❑ I, as owner of the property, or my employees wilh A�DRE55 . .
woges as their sole tompensotion,will do the work ond- ��TV tEL n10. - -
ihe s�ruct�re is not inlended or ai/ered for sale(Seclion �
704A,Business ond ProFessions Code). . , ,
pWNER T�7illiam L-on Con an -
❑ I,as owner of the property,am exclusively coniraUing
with licensed contractors to construd the projetl�Sec- � ��� - � '
tion 7044;B�siness and Professions CodeJ. aDDRESS 19 COI' orate PldZd
CONSTRUCTION LENDING AGENCY � CITY N2WjJOIt IIeach 92660TEt.N�714) 833-3600
I he�eby affirm thot there is a construction lending agency for ,
the pe�iormance of Ihe work for which ihis pe�mit is issued- COMRACTOR � � - . � �
(Sec.3097.Civ.C.). .. . . -. . . .. . .
- ADDRESS � - - �� ' - . . _. .
Lender's Name V � '
Lender's Address ��TY OYdII e Ca 92665 TEL.NO.�714) 921-080 - - - - -
I certif thor I have reod this a lication and s�ale�hat the S7AiE tiC.
y pp LICENSE NO. � �}6H6O9 -CLASS� C—IO . .. . ... -_ . ._ . ,
above informa�ion is correct.I agree to comply with ail County �
ordinonces and State lows relofing to building construcfion, . . _ _ .
and hereby auiharize�epresenta�ives of Ihis Coun�y b enter � � ' � - .
up n the above-men�io�rty for 7nspection pu�poses. SEE REVERSE FOR EXPLANATORY LANGUAGE '
- -
7-23-87
$i t�re of Applicon�or Agenl - Date -� . � �" ' ' ' "" ' --' ' "' -- '
. --; -- -- - ; � -;-
, � . I � .` � ' i
M �
. � � �
�I , Ir _.. . � � '
/ . . L _.. ' i � I ' S i i � . .
. ;
�� . j j •
z �� . ' . � ' ' . .
� 1 •
� � (. � .
m �". � . -
O . � - .��<. ' ' . ' , r
N . • i,, i . _.
0 , , '�, • _ . . ; .
,,,� ;
m ,
N �
. � . , . • i � - .
' ; , � � '. ,.. t� . .
� � . ' ' : � �i . � ' �� .
ii '. .. . . _ . ,��. .., . ._ - , ' ... . � - . . .
� , r
� � . . . _. _' . .�- - . _ .
�
1 � ' '
' 1 � � ,
j
� � � ' ' � .� . u ' -
_ , . j ,n
I. , , a
. � ; �
. .. . . .. . • N
i - .�
- 4
� O
. ;, I , ' � � ' , �
, �� , , . . � . - .. H .
' . .- �. . . • : . . � �
. � _ . . � : � , ;.� ' _ : . .
� _ . , . . � � .. . 4�. , .
Q � w - �.cFo'.inp: 4 ° � � F 'Fo.�s oo:o0�:�03:� o � p= - -
p . o n „ �-N.� „ f os� oa � w -, o � m ,n oT
� �. i� R° . 3 n�-o -n _ a,i�° � 'x-° ,�n..N n„ N � y � 'o �..j � o
� � ° � ?vc.'"i' o''o ❑ c °c° �sc^oc ❑No �"on.� o �"QNNm �
- � � � �°• ciN�'A, £ - a�.3 �'3 a� i� yo�o aoS =m' o 0 o a.
- 0 3 ^ ^ mmso � a� � o '" ac� 'o ° o"• � n`'o'l^.oa° �� cf ^ �
� v o'�N _ .m � o,�e e-N _. o . <_.�c� o.�..� �,� �o - .
? N � n � 0 3 - � o '" � -. _o ,� o>n N �.p 3 �0 3 'Z ,
. N. � , ,_f'3� 3 o f t F N �o . �.N o � �.a a-�-�•o:�o q � a m .
�-'n a N � ' o �o c, � 3 Q, � � m.v�� � o'' o � c o s 7v
' . . . . .. �� �.c� � , n .o o�'" � � 0 T a�a� � � � o �o n k T� � N ^ a « m� .p .
� � Q d o � p�rJ o• ��� ��n c �
' i - � � o o�.� o ao.� ° `m F.0 aN � a� s '<' 3�3 .�; o o aU m > > o e �
, o. .
� ' � � = n °o ,�o 0 o v 4�° .� a. � �-o o av j�b:..� w nc 7� �o F m � '
" ._ . � F r, - n C � x 7l7
� - - . ^ n v m o a c o _ �.v� N o D o o � �3 �a c v o _ �� � cu
" ' - • � � `�'« �o � C� s�o'� � ° � � D�-T�'� e� a `� 3 0
, a o o - -9 � 3 0 -D �
• � • `"-'o ° � o� ,°„ �of3� o �,'. �f � 3 � ,�.p�-o` � - ° � o .., n
� _. . . -n�� no p m.O.� oro � � na_ - 5. �c 'O=.$ " �. n o o . �
. . - : -. � ' ' . � o� ,�� x 000�' ,`of � `D° o �°'O. 3N3� Q �� ° '^ s "D'� .
�- - " , an � �; � 0� 3 �� ooyo �- -•.N � n `" 3uN ? o ^ �D �Q
� o ��- N`.'°ro m� �_'n� ,`n ' o.'a> > ��o ° o n Z
'. ' � . � 3 ° �?� �-ocNo '� ': F �. ��-^.� a' o' � ?
' . . , c O v o � o 0 4 o N b o ° c� a,� �� a°3� "
� Nv° �o^ o' Sa . v° 3 •'r aa ,�,.e-'o� °.uoof'�$°
� -� o � � .a o � '� o F 'o' _. �-_o
� - ' � om as � „ � o � aaaum s.. � � .
o °� ^• � ' 4 0 ° ° �-� ^ a o�-� � , �-m m r� i��u� �,