HomeMy WebLinkAbout1163A (5) � WORKERS"COMPENSATION DEC�ARATION �
I hereby affkm thar I have a�e.,����a,e af�a�5e���o se�f � APPLICATION FOR PERMIT
insura,or a ce�nfim�e of Wo�kers'Compensotion Insurante, 76A3baC HEATING - VENTILATING - A�R CONDITIONING
� or a certified topy thereof(Set.3800,Lob.C.) �
'CE-918(REV.10/Bl) - . �. � LG f,��J' 9
P❑olity No. l f191 ril Fi Compony �Si'�tA.Fnnd - '
Certilled copy is hereby Furnished. TR�r 44824 �OUNTY OF LOS ANGELES Jpgn �1111 BUILDING AND SAFETY pgn 4.
� .Cer�➢Ged capy is filed with ihe coonry building inspec- FOR APPLICANT TO FILL IN BUILDING
tiOn department. (PRIM OR TVPE ONIY) � ADDRES$
Da�e����—nT,.,� Appiicont �OCAUN Diamond BaY
NO. NPE OF APPLIANCE OR EOUIPMENT FEE �
CERTIFICATE OF EXEMPTIO ROM WORKERS' niEaaEST .
COMCENSATION I SUF2ANCE Ck055 ST.
� (Thls sactlon need nof be tomplatad IF iha work Invalved by ABSORPTION UNIT,BTU OiSitriCi NO. vRp�E55E0 BY�
The permi}Is(or one hundrad dollon(SI00)or lass.) qIR HANDIING UNIT,CFM a `�'Y�.��
I certi(y ihat In�he performance of the work for which fhis�
permif is issued,I shall not employ any person in any manner gp��ER,BTU
_ so as to become subject 10 the Workers'Compensation Laws. , nPvaova�s DATE INSPECTOR'S SiG ATURE _
Dote - opplicant � COM7RESSOR,BTU ROUGH �,�
NOTICE TO APPLICANT: If,�after making this Certificate o( - VENTRATION SYSTEM FMAL � (� .�^,,
Exemp�ion, yo� should become subject lo the Workers'
Compensorion provisions of the Lobor Code,y0u mu5f fOflh- EVAPpRATIVE COOIER VALIDATION
with comply with such provisions er this permit shall be
deemed revoked. � � FURNACE: FAU-7�GRAVITY .
IIGENSED CONTRACTORS DECLARATION FLOOR BTU
1 hereby affirm thal I am licensed under provisions a(Chapter 9 HEATER: SUSPENDED UNIT_ �
`(commencing wilh Section 7000)of Division 3 of ihe 8usiness ' wALL .
and Professions Code,and my license is in full force and effect. � � . . p�',
O
license Nomber�y_lic.Class��8 � - ,
�
Con�roaor Irvine47est paie 7-23-87 . . - _ -- - ---- - - -- O
r
❑ I am exempt under Sec. . . . � . . � � �
Plcn check fee �
B.BP.C.for rhis reason' . . �
PERMIT ISSUING FEE S �
Da�e:
:11 (�3A
TOTAL FEE �} ',t, . . . . .g
Signoture � .
� OWNER-BUILDER DECLARATION fl.nN CHECK APPUCnN7 �
1 hereby offirm that I am exempt from ihe Controcbi s License � - �.• •Q$�� .
law for ihe following reason(Section 7031.5,Business and NAME .
Professions Code): . � • ° •�u�G"
❑ I, as awner of the property, or my employees with ADDRESS � , ��.��—£j']
woges a3 their sole tompensation,will do ihe work and � GITY TEI.NO.
. �he structore is not iMended or offered for sale(Section � �
7044,Business and Professions Code). . - � .
OY✓NER
❑ I,os owne�of the property,am eaclusively tontroc�ing m an
with licensed tomractors b mnsl�uU the project(Sec- MA�� � - �
. tion 7044,Business and Professions Code). ADORE55 2'dte.PldZa
CONSTRUCTION LENDING AGENCY - - � CITY N0W Or't Deach 92660TE��"Q�714) �II33-3600 -
I hereby offirm that there is a consvuction lending agency for , �
Ihe performance of ihe work for which this permil is issued CONTRA�'fOR " �' ' ' " ' ' ' -'
(Sec..3097.Civ.C.). _ . -- - . . - . . .
. . ADDRESS . . . _ . .. . . . . ' _ � _ . _ � .
lendei s Name
. CITY _ TEL.N0. 4 9z1—O8� . . . ._.. _ . . _ . . .
. lender's Address
STATE - LIC. '
I certify Ihat I have read Ihis opplicotion and state tha��he ,� LICENSE NO. Q6Bfi09 �� - CLnSS C-20— -- � ----- � - �- -� � � � � � . - �
' a6ove information is corretl.I agrea lo mmply with all County �
ordinances ond Slale lows relpting to building tonsiruction, _ -
and hereby outhorize�epreseMa�ives of this County to eNer � � �� - � � � �
�n�_ve-menti n_ g e�rry for inspeciion purposes. SEE REVERSE fOR EXPLANATORY LANGUAGE ' _
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