HomeMy WebLinkAbout1161A (5) WORKERS'COMPENSATION DECLARATION �
. I hereby affi+m that I have a tenificote of�o�,e��,o se�f � . APPLICATION FOR PERMIT .
�nsure,or a ceriitiw�e of Worke�i Compensaiion Insurante, 76A�� HEATING - VENTILATING - AIR CONDITIONING
� or a certified copy thereof(Sec.9800,Lab.C.) � CE-818(REV.10/81) � '� �
P❑olicy No. 7 f171 Sl F Company Gtdte�FL71f� - " �0���
Certitied copy is hereby furnished. TR� 44824 COUNTY OF LOS ANGELES JOBn 1111 BUILDING AND SAFETY PH$ 4
� Cert@Ged copy is filed wiih the coonty bvilding inspeo- FOR APPLICANT TO FILL IN euitDiNG
lion departmenf. - AODRE55
(PRINT OR TYPE ONLY)
Date 7—a�—$] Applic - b�.G LO�AUTY Diamond Dar�
� NO. TYPE OF APPLIANCE OR EQUIPMENT � - FEE
CERTIFICATE OF ExEMPiI FROM WORKERS' NEaeEST
COMPENSATION INSURANCE ' cao5557. '
(This seclton need nof be'compbled if fho work involved 6y ABSORPTION UNIT,BTII oiStatCt No. vap�E55E�Bv
the permif is for one hundred dotlars(5700)or less.) �_ �y,� ' r
I certify thaf in Ihe perlormance of fhe work for which this- AIR HANDLING UNI7,CFM �+"(J l✓ .
— permit is issued,I shall not employ any person in any manner BOitER,BTU
so as�o become su6ject to the Workers'Compensalian lows. nvraovn6 OATE INSPEC70R'S SIGNAfI1RE "—
Da�e epplicant COMPRESSOR,BTU 0 lO OO ROUGH
, NOTICE TO APPUCANT: IF, ofier making this Certificata of VENTIL4TION SYSTEM FINAL
Exempiion, you should become s�bjett to �he Workers'
Compensotion provisions af ihe labor Code,you must fonh- Evnt+oeqiroE COoieR � VALIDATION
' with comply with wch provisians or lhis permil�sholl 6e
deemed revoked. � � . • FURNACE. FAU�GRAVITY
LICENSED CONTRACTORS DECtARATION-� FtOOk BiU 10 O
I hereby affirm Ihat I am licensed under provisions of Chopter 9 . SUSPENDED 11NIT_
HEATFR: WA��
�(commencing with Sec�ion 7000)of Division 3 of the Business � }
ond Professions Code,ond my license is in full force and effect. O e !7� a
O
Litense Number 468�99 ���-Clon�—�n_ - , V
CoNmctor Irviaet9est Dale 7-23-8'� . . . ... . �� � �x� A �
❑ I am exempt vnder Sea � . . � � • •8 w �
Plan check fee • 4
N
B.BP.C.for rhis reoson pERM1T ISSUING FEE S ?
Date: "10 50 I • •L'$C�
Signoture TOTAL FEE $ !70
- OWNER-BUItDER DECIARATION PLAN CHECK APPLICANT - � • � •4 C�O�
I hereby otiirm thot I am exempt irom the Contractor's License � ����J_8 7
Law for the following reason(Seclion 7031.5,Business and NnME -
� Professions Code�: � � - , �
❑ I,as owner of the property, or my employees wi�h ADDRESS ,
wages as their sole compensalion,will do the work and .
Ihe sfructure is not inlended or of(ered for sale(Seclion ��iY TEL.NO.
7044,Business and Pro(essions Code).
� OWNER SJilliam L on Com an
❑ I,as owner of the property,am extlusively contratling
with licensed mnirac�ors to tonstrud the projecl(Sec- �'�� � - - �
fion 7044,Business ond Professions Code), ADDRE55 19 COr ora..e P12Zd
CONSTRUCTION LENDING AGENCY - Ctiv tlewport Beach 9266d�E�.Nq.714) 833=360 �
I hereby affirm that there is o construc�ion lending agency for ,
Ihe performonce o(the work for which Ihis permit is issued CONTRACTOR �"� � - -' -� -�� -��
(Sec.3097,Civ.C.). . . . - - .. . . .. - . .
- � -�� - ADDRE55 - - �� - . .
Lender's Nome r Ve. .
arr Oran e Ca 92665 TE�.No.(714) 921-08 0
lender's Address �
STATE lIC
I cerlify Ihot I hove read ihis applicotion and stole thot ihe uceNse No. 468609 CLASS C-2� . . . . _ .. .. . .
above informotion is correct.I agree�o comply with all Counry -
ordinances and Srate laws�elating�o building tonstruction, �
and hereby authorize representmives of�his County to en�er � �- � � � � � �� � �� � �� �� �� �: �� -
/J upon the obove•meqrioned property For inspeciion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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