HomeMy WebLinkAbout1162A WORKERs�oMPENSAT�oNOE«ARAT�oN - � APPLICATION FOR PERMIT �
I hereby affi+m Iha�I hove a ceni(icate of consenl to self .
insure,or a cerrificote of Workers'Compensotion Insuronce, �ansaac HEATING - VENTILATING - AIR CONDITIONING
or a tertiiied copy thereof($ec.3800,Lab.C.) . .
CE-B18(REV.10/81) - � - � �f[ap
P❑oliq No. 7 021 51 6 Compony State FUIIG� ' � � �
Cerrified copy is hereby furnished. TR$ 44II24 COUNTY OF LDS ANGELES JOBn 1111 BUILDING AND SAFETY PHn 4
� Cer�P4'ed topy is filed wi+h�he muny build�ng inspec- FOR APPLICANT TO FILL IN su��o�t�G
fion depor�ment. . (PRINT OR TYPE ONIY) ADDRESS 20754 East Nll�.l Lane �
Do1e 7-23-87 App��cont �«^��n Dianond Bar .
NO. TYPE OF APPLIANCE OR EOUIPMENT FEE -.
CERTIFICATE OF EXEMPTION OM WORKERS' NEnREST, . �
COMPENSATION INSURANCE Ca055 5T.
�(Thls sodlon naod nof ba compla}ed if 1he work Involvad by ABSORPfION UNIT,BTU DISTRi�i NO. PROCESSED 9Y . '
fhe permft is for one h�ndred dollors(SI00)or Iess.J `� �,y� �J�
� AIR HANDIING UNIT,CFM
� I certify ihat in the performance of the work for which�his . v / '"
_ pe�mit is issued,I shall not employ any person in any manner BOILER,BTU --
so as to betome subject 10 the Workers'Compensation Laws. . nevaovais DATE INSPECTOR'S S�GNATURF
Date Appiicant � 1 COMPRESSOR,BTU IO OO ROUGH �
NOTICE TO APPlICJ1NT:.lf, after moking ihis Cerlifimte�of vENTiwTiONSYSTEM FINAL
Exemption, you should become su6jeU ro the�Workers'._
Compensalian provisions oi the Lobor Code,you must forlh- EVAPpRATIVE COOLER VALIDATION
with comply wi�h such provisions or this permit sholl be . �
deemed revoked. � FURNACE� FAU_X—GRAVITY� ��
� LICENSED CONTRACTORS DECLARATION FLOOR ettl 10 00 .
I hereby affirm ihot I am licensed under p�ovisians of Chapter 9 HEAiER: SUSPEN�ED UNIT_ �
�(commencing with Section 7000)of Division 3 of the 8usiness wAU
and Professions Code,and my license is in full force and efietl. - , � - � a
y o
License Number � Q�$�Q9_lic.Closs�—�Q - - - - � � V
IrvineTdest 7-23-37 ► �
Contmctor Da�e � � --- � .
�
❑ I am exempt under Sec. . . . . . . .. . ' V
Plan check fee W
B.BP.C.for Ihis reason � �
Date: PERMIT ISSUING FEE S 10 50 `�„� G 2'� z
Signamre TOTAL FEE _ S ' �'• • • •8
- OWNER-BUIIDER DECLARATION Pl/+N CHFCK APttICANT � I ° •Jr 1.O O
1 hereby a(firm that�am exempt from the Conhactor's License� � �
Law for the following reason(Section 7031.5,Business and NAME ' � •J.�i�Q=
� Professions Code): " -•
❑ I, as owner of ihe properry, or my employees wi�h ADDRE55 - C E C J—8 7
�� �wages as�heir soie tompensation,will do the work ond��
- the shutfure is not inlended or offered for eale(Setlion CITY TEL NO.
7044,Business and Professions Code). � - � �
OWNER plilliam L on Compaay
❑ I,as owner oi the property,am exclusively con}racting �
with licensed mntractors to conslroct the projed(Set- MA�� - - �
Ilon 70d4,B�ziness and P�ofessions Code). ADDRESS 19 Cor orate Plaza
CONSTRUCTION IENDING AGENCY oTv Nei�ioort'Beach 92660���N4�714)'333-360
I hereby affirm that there is a cans�ruction lending agency for ' '
the periormonce of Ihe work for which this permil i5 issued - COMRACTOR- . � ��-�- " � - ""� "" --"•
. (Sec.3097.Civ.C.). . ' ' ...._ . . . _. . . .
.. .. .. .....
. '. AD�RESS �' ll hern'Ave:.. . . .. . .... . . -i� ''_... .. . �
Lender's Name ����� .. ._ . ....
��T� Oran e Ca 92665 TEt.No.(714) 921-08 0 �
lender's Address �
I certify that I hove read this opplication and srate that ihe LiCENSE NO.-- �468609.. . . ClASS C-20 .._. . . , . . . . �
obove informa�ion is corretl.I agree�o comply with all Counly
ordinances and State laws relming to boilding consnuUion,._ .
and hereby outhorize reprezemalives of ihis County to enter � � �� � � � � �� � � � � ��� � � • � -�
upon tha above•me �ioned propeny for inspec�ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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