HomeMy WebLinkAbout1123A VlO�KERS'CO:"•PENSATIO.'JDECLA4ATION qpp��CATION FOR PERMIT �
I hereby affirm ihot I have a certificate of consent to self
insure�or o cerli(ica�^o�wo.ke�•Comp��sorio�I�surance, �6A3AnC HEATING - VENTILATING - AIR CONDITIONING
ora cr�tlfied copy hereof�Sr.c...500,labr C.) CE-81B(REV.IOiAI)
O1 IVCG_119�JA SuDerior Aational
PoLty�Vo. COmpnny
Q c�e�ulied copy is hereby furnished. COUNTY OF LO$ANGELES BUILUING AND SAFETY
� Ce�i�(�ed copy is f�led wirh the coun i u� �n. ' � ec- FOR APPLICANT TO FILL IN euno'N�
lion epo�menl. �PRINTO'+TYPEON�Y) ADDRESS 114Q �c�]]�.'�1�ti00C� Place
oo�o Appliton � �aA��T� Diamond Bar
NO. TYF'E CF AP?LIANCE OR EOUIP'lENT FEE
CERTIFICATE CF EXEh1 ION.ROP.1 VlORKERS' �E�RES7
COh".PENSATI N I $URANCE CRO55 Sf.
�ihis�acfion nood not he ca atad tf rha work Involv.d by ABS07PTI04 UNIT,BTU �i,iw,��h� Cv�kSSID 9Y^
fha permif fs for ona hundred dollars(SI00)or less.) 1 O `\
I cPrtify Ihal in Ihc pr,�formoncc of Ihe work!or which Ihis nlq HANp�IhG UNIT,Cf�,�
permit is issued,I shali not employ ony person in any manner ���}�
so as lo becomc subjecf fo thc VJorkrrs'Compensolion Laws. e0!IER,BTU nonaOvaiS � nniE iNS�F[iea'S Si�YaruaE
Dair. Applicon� CO'/.FRES50R,BTU_ O � O � ROUGIi
hOTICE TO APPIICANT: If, aftcr moking Ihis Ccrti(icate of VENTILATICN SY57[M F!NnL ,Y�,
Ezemplion, you should br.comr. subjcct lo Ihc NJorkers' -- -
Compensalion�rovisions cf Ihp Lobo�Cod=,you m�st fo�th- [VAi�p7ATIVE COOIfR VALIDATION
wi+h tomply with such prOviSiCns or Ihis permit Shall bc
dcemedrevoked. FU4NACE: FnU_GRAVITY
LICENSED CONTRACTORS DECIARAT10N FIOCR oiU
I hereby effirm thol I om licensed undsr provi5ions of Chepl?r 9 HEATFR: SUSF'E�CED UNiT_
(commencing wi�h Seciion 7000)of Division 3 oi Ihe Ousiness " �v�«
and Profess�ens Code,and my Ilc�nsr is in full force and r.ifrct. y
r O
licr.nsc Num6cr 31�1�3 ;�,�lass C Z� , V
r a
Contmc _ afe. �
F
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W
I am e.empl un e� ec. plan check fee °�
..RP.C.fcr Ihis recson �
PERMIT ISSUING FEE S �Q
Z
Dn�r.:
siqnaiure TOTAL FEE `�Q
O`VNER�3URDER DECLARATION ' CHECK ACFLICANT
I hereby a(firm that I am erempi(iom ihe Conrractor's License • ,
Law for tFr.following reason(Section 7031.5,Businr.ss and Nn�•E
Pro!cssions Cod�):
i ❑ I, as ownrr of Ihe�roArr�y, or my cmnloyee.s wilh ACCRE55
woges os iheir so!c compr.nsa!ion,will do!!�e wo.k and
�he strucWre is not iniended or offered for sole(Section CiTv TE�.NO. y
70aa,�us�ness and Professions Code). '�� � 2''�
� o�:'"`R Sahara Pools �a
I,as owner af ihe prnp�rty,am r.xclusively conrractin� ��• • • •
with licensed centro:tors io cons�ruct the project(Sec• pD^4CSS5�� j�. Cienega
ticn 7044,B�siness a�d Prefess�ons Code). I ^ •?_G 5 0
CONSTRUCTION LENDING AGENCY CiivSc"lIl Dimas TEL.h0
I hereby affirm�ho�ihere is a tons�iuclion Icndint�o�enty for , °° •=Q J�2za
�he periormance of�hr.work for whfch rhis permii is issur.d � COVTR�[T(C�Dl'lll A. Pfartin f�tCJ. � n�L' O�2&`II 7
(Sec.3097,Civ.C.).
aoo�ess 442 �q, gpnita Avc.
Lender's Nome
��TYSan Dimas Te�.no599-2901
Lendr.r i Address
STATE UC.
I ceriify ihar I have reod�his opplication and s�a�r.�h�t the ucen,se No. 315103 C1a55 �-'ZQ
abovr..Information is correc�.I agree�o comply with oll Couniy
ord�nonces o^ S�a�e laws rr.lntinq to building tons!r�ction, . I
� nnA hereb � m re^resentaiives of ihis C unly 10 .Nr.r
� �h � v me. c ed o r� (or in^�tion ur oses.
�� \ �" Y SEE REVERSE FOR ExPLANATORY LANGUAGE
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