HomeMy WebLinkAbout0864 (4) 4YORKFRS'CO.lFENSATION DECIARATION �
I hcreby o(firm�hot 1 hnve o cerrfico�c of conscn��0 5��� . APPLICATION FOR PERMIT
�nsure,or a cerrlica�r.of Worknri Compensoron��s��a�ce, • HEATING - VENTILATING - AIR CONDITIONING
or a cr.rtified copy�!�ereof(Sec.3800,Lob.C.) 76AJ�eC
��. S+�G11190 A Sunerior i�ational CE-818(REV.10/tll)
�cy o. Compon�+ COUNTY OF LOS ANGELES BUILDING AND SAFETY
Cerlified copy is hereby f�rnished.
� CPlIiIiPd C PY is filed wi�h�he tou ry �ild�,g��sped� FOR APPLICANT TO FILL IN eu��o:NG
�io .eparmenl. �D�RE55 1371 Ran eton Dr.
� �P,�INT O4 TYPE O\LV)
�Do�c Applicant ti L 1OCAL1TV Diar�or.a Bar
\J �O. TViE OF Ai+o�IANCE CR EOU:P:•FNT FEE
ERT ICA E OF EXEf.1aTl .ROM L'lORKERS' nFnR[Si
CO:'PENSATIOP I SURANCE caosssr. Glenbrool:
(Thi�s�etion nosd not be com eod if Ihe werk involvad 6y p'��Q'��`7N UNIT.ATII o�ir�u�o �voass!o xr
fh�pa�mH fs►or ona hundrad dollars(f100)or la�s.) ��
I cerlify�hnl in Ihr,per(ormonce ef Ihe work for which this AIq fiA�DIING UNIT,CFA1 'Z
permil is issu?d,I shall not r.mploy any�e�son in any manner �
so ns to becomc subjett�o rhe Nor4ers'Compensn��on Laws. e0'IFR,RTU pF�o0VAl5 AaTE NSMC702'S 5�4N4T�PF
Datc Applicont CO'!PRE5504,BTU ROUGH
I�OTICE TO APPLICANT: If, oftoi r�oking ihis Cr.r�ificaie of VEr:TilnTiOV SYSTE�.1 FiunL
Exemp��on, you should become svbjecl to 1hr. LNork�rs'
Comnensa�ion provis�ons of�hc Labor Codr.,you musl iorih- EVAf�O4ATIVE COOLER VALIDATION
winc �omply wiih such prov�siens or Ihis permil sholi be
deemedrevoked. FURNf.CE: FnU `-G4'V�TY ^ ��''
IICENSED GCNTRACTORS DFCIARATION I FIOCR BTU Sf�F/l-�J`�i JI� �
I hereby a!(�rm�hai I am licensed u�der p�ovis�ons of Chnpter 9 M�ATER: SUSPCM1JED L'NIT_
(commencing w��h Sec��on 7000)of D�vision 3 oi�hc Business ' �"/A« r
and ProFesslons Code,ond my I�cense is in full force and e.F(ect. �y
L�cenSrtNumbrr 3151C3 �,ClossC C20 p$�� a
co���o ` � I?�5 , � � o
;'d:K�,ii�j u
❑ I nm .�empi under Sec. plon cheCk(eC � � �2 r �
. P.C.for�his reason � �."� Z
p�1e: PERMIT ISSUING FEE S G . .2 Q,j(��
TOTAL FEE „Q �j� �C G�'� �
signarurr. _ .
OLYNER-BUILDE4 CECLARATION �l�N� . FP�I�ANT
I hcreby a�firm Iha�I am c.emp�from�he Con�ra:�or's License ,
Law fo��hc followin9 reoson(Sec��on 7031.5, 6us�ness and N4�•.E
Professions Code�:
❑ I, os ow�er of�he prcper�y, cr r�y emptoyees wirh � ��DRESS
wo�rs os iheir sole compensotion,will do Ifie work ond Ci{ TFL.NO.
ihe.slr�Uure is not iniended or oifered ior sale(Sec�ion i
70E4,Business and Pro!essions Code).
❑ O:':tiER �;;�rles Bunberger
I,os owner of�he preperty,am exclusively confroc�ing
wiih Gcensed com.ac�ors io construci�he project(Seo- ��'A�� �`
a0�2E551371 ?RP.R �tC?? Dr.
lion 70A4,Busire:s ord Profe!sians Cedr.). C �� y�,p� b V
CONSTRUCTION IENDING AGfNCY ��T�jiaMond Sar TEi.hcS��-6607
I hereby affirm tho�ihere is a cons�ruc�ion Innding agency For ►
�he performance of the work for wh�ch ihis p^rm��is issued CONTRaCTC�0i1n a. j✓,a_r,'-,lI] �'i�_.& h.C
(5=c.3097,Civ.C.).
noc�ess�c,2 Ft. �3o^it= Ave. �� L \ �'�
Lrnder's Nome
°T�aGr. Dina� rE�.r,o 5°4-2901
Lender's Addrr.ss "
sTnre 3��_03 uc CLO
I tertiiy tha�I have�ecd�his applicaiion and stn�e ihat ihe IICFIhSE Np C�nSS � . .
obovc in(crma�ion is torre[t.I ogree lo comply wi!h all County
ord�nanc�s and Sto+e lows rela�ing io bu�iding consirociion,
and herc a�rF�r ze represen�aii� s of this County to enter �
�uR�ty,�h. o��men in ed rnoe� �r inspec�n. porp scs. SEE REVERSE FOR EXPLANATORY LANGUAGE
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