HomeMy WebLinkAbout1179A WORKERS'COMPENSATIONDECLARATION � APPLICAT�ON FOR PERMIT �
I hereby offirm that I hove a ce�tifico�e ol consent to self -
insure,or a ceriifim�a of Workers'Compensation��so�a��e, � � � . � ���HEATING �--VENTILATING - AIR CONDITIONING �1
or o cert10ed copy Ihereof(Sec.3800,Lab.C.) 76n36eG �-
ce-eie�aev.ioiei j. _ L.vtAF�fs"
P❑ol�'cy No. �n�i ai s, Compony Gtate Fund . �� �
Cerrified copy is hereby iurnlshed. TR'n 44824 COUNTY OF LOS ANGELES JOI3# 1111 BUILDING AN�SAFETY PHn 4
� Cert�yed copy Is liled with�he county building inspec- FOR APPLICAN7 TO FILL IN � BU�LD�NG ' .
tion deporfinent. • - ADDRESS 20747 East Mill Lnae
� , . ^ _ �� �FRINi OR TVPE ONLY)
J
�Date��.3 8a APPlicanf'L .Y'� tocnurv Diamond Bar
. NO. � TYPE OF APRIANCE OR EQUIPMEM - FEE
CERTIFICAiE OF EXEMPTIO OM WORKERS' NEAREST
� � COMPENSATION INSURANCE GRO55 ST.
(Thfs soctton nood no1 ba tompiated if th�work Involved by, ABSOR7TION UNIT,BTV DiS�Ri�!NO. VRp�ESSF�BY
fhe parmll la for one hvndred dollars(S100)at less.) - �
I certify thot in ihe performonce of the work for which lhis AIR HANDI�NG UNIT,CFM �—y� /, �
o ' � 1/��
permit is issued,1 sholl not employ any peison in any manner gOILER,BTU � �
so as�o become su6jeU ro the Workers'Compensalion taws. . nrvRovn�s DA7E �NSPfCiON'S S�GNATUFE
Date Applicanl ' COMPRESSOR,BTU jO OO ROUGH �T(7y$Z
NOTICE.TO APPIICANT: I(, afler making this Ce�tificafe of VEN7RATIONSYSiEM - FINAL (/\��
Exemption, you shoold�become sub[ect ro the Workers'
Compensafion provisions of�he Lobor Code,you m�s�for�h- EVqPpRATIVE COOI.ER ' VALIDATION
with comply with such provisions or fhis permit sholl be
deemed revoked. FURNACE: FAU�_GRAVITY .
� � LICENSED CONTRACTORS DECIARATION Fiooa aru� 10 00 �
- I hereby affirm Ihaf I am licensed onder provisions of Chapter 9 � NEATER: SUSPENDED UNIT^ -
"(commencing wilh Seclion 700D)01 Division 3 of�he Business WALL
and Professions Code,and my litense is in full force ond ef(eU. � " . - . � �y
O
Ucense Number ��wT_lia Class- e g8 - - , V
conr.ador rrvineWest paie 7-23-87 �
O
❑ V
1 am exemp�under Sec. a
Plcn check fee ., , ,.7 9 a �
8.8P.C.for this reason pERMIT ISSUING FEE S' 10 SO
Dme:
Signawre TOTAL FEE � #• °. •B
OWNER-8111LDER DECLARATION PLnN CtiECK AVMiCnNi � . ' -� � � '�J O O
I hereby aifirm that I om e=emp�from the Contracror's License� � '
Low for the followinq reason(Setfion 7037.5,Business and NAME ' � � ' °Jr 1 U J�
Professions Code�: . .
❑ I,�os owner of ihe property, or my empioyees with aDDRE55 � ��O`3.—`a'7
wages os iheii sole compensotion,will do Ihe work and ��T� 7EL NO. � �
the strucrure is nef inMnded or oifered for sale(Seclion � .
7044,Business and Profeesions Code). . -
� OWNER ,1117.dtt1 L OII COIfi dIIV
❑ I,as owner of Ihe property,om exclusively contracting
with licensed conhadors�o mnstruc�the project(Sec- �"�Ait ,
� tion 7044,Business ond Professions Code�. � A�DRESS 19 COZ orate Plaza
CONSTRUCTION�ENDING AGENCY - - ��T� Ne���port Beach 9266QE�•No(714) 833-360 �
I hereby offirm that there is a canstruction lending agency for ,
the performance of the work for which Ihis permil is issued fONTRACTOR � ��� ----" -- �
(Set.3097.Civ.C.]. � - � . ._... . . . . . ..
. . ADDRE55 . . . .. _ . .. . __.. . . .
Lender's Nama �
aTr an e Ca 92665 TEL NO.(714) 921—OS 0 -
Lender's Address
I cerlify that I hove�ead rhis opplicotion and state thalJhe iiceNse rio. 465609 C A55 �C-Z�.._ . . __ .. . . ... . . ._ . . ,
above inio�mafian is cortect.1 agree lo tomply with oll County .
o�dinantes and State lows reloting to 6uilding construcfion, .
and hereby au�horize represen�a�ives of this County to enter " � � � -� - � � �� �� � �� � � � �� ��� �
upon tha above-mentioned property ior inspedion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE _ _ . __
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