HomeMy WebLinkAbout1150A (7) . WORKERS'COMPENSATION DECLARATION ppp�ICATfON FOR PERMfT �
I hereby affirm that I have a cerrificate of consen�lo self
insure,or o certificate of Workers'Compensation Insurance, �bA�aoc HEATING - VENTILATING - AIR CONDITIONING
or a cer�ified copy thereof(Sec.3800,Lab.C.)
CE-818(REV.10/81 j
O�Y N�� �n— �.�6_Compony state Fund Lo t#��
Cer�ified copy is hereby furnished. TR� 44824 COUNTY OF LO$ANGELES JOB# 1111 BUILDING AND SAFETY PH� 4
� CertP(ied copy is filed wi�h ihe county build�ng��sPao- FOR APPLICANT TO FILL IN euimuvc
tion department. ADDRESS
�PRINT OR TYPE ONLV) 1 East Rim Lane
�ate 7—?,jm.��� ApPlicant LOCAtI7Y
CERTIFICATE OF EXEMPTIO OM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMEN7 �E NEARESI Diamond Sar
COMPENSATION INSURANCE CRO55 5i.
(Thta ceclion n�ad not fw complafod if fh�work involved by Ag50RPTION UNIT,BTU DISiRICT Np, PROCESSED eY
, �hs p�rm�f Is for one hundrod dollun(5100}or IQss.) � � �
I cerfify that in the performance of Ihe work for which ihis
AIR HANDLiNG UNIT,CfM '
permit is issued,1 sha�l not employ any person in any manner
so os to become su6jecr io the Workers'Compensation Laws. eOiteR.BiU APPROVALS un� INSPECTOR'S SIGNATl1RE
1 COMPRESSOR,6TU 4H�OOO I.O OO �UGH
Dafe APPlicant ��
NOTICE TO APPL�CANT: if, after making this Certificale of VENTItATION SVSTEM FINAi ���� L1�.
Exemption, you ahou�d become s�bject to Ihe Workers'
Compensation provisions o4 the Labor Code,you must forth- EVAPORATIVE COOLER VALfDATION
with comply with such provisions or this permit shall 6e
deemed revoked. 1 FURNACE: fAU_G&�ITvvO— 1� 00
LICENSED CONTRACTORS DECLARATION FLOOR B7U '
I hereby affirm that 1 am licensed under provisions of Chapter 9 HEATER: SUSVEN�Eo UNIT_
��commerrcing with Section 700D)of Divisian 3 of the Business - WA��
and Rofessions Code,and my licensa is in f�ll�force and effecl. !�
INLETS & OULETS a.
468609 c-20 u
License N�mber Lic.Class � �
3rvineWest 7-23-87 � O
Contractor Date �
F
❑ I am exempt under Sec. ;::� � �/;}1 W
Pion check fee t, . . e .� N
8.8P.C.for this reavon pERMiT ISSUING PEE S 10 50 Z
Daie: � � , r.,r��s n
Signotu�e TOTAL FEE ` '� -
. . a G r, , „x
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ' ' "�'`
I hereby aFfirm rha�I am e�empt fram the Contrador's License ► U�.;V�—ii(
Law for the following reason (Seciion 7031.5, Business ond NAME �
Professions Code):
❑ 1, as owner of the property, or my employees with ADDRESS .
wages as iheir sole compensation,will do fhe work ond . �
the structure is not intended or offered for sale(Seclion CITY TEI.NO.
7p44,Business and Professions Code).
OWNER �'lilliam Lyon Company .
❑ 1,as owner of the property,am exci�sively controcting
with licensed contracbrs to consrruct rhe projecl(Seo- o�ae55 19 COTpOY'dtE P 3Zd -
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY ��TY N2wpOit BedC Et.N .
I hereby affirm tha�Ihere is a consfruction lending agency for � � .
the performance of the work for which this permil is issued coNiRncroalrvineWest H'tcJ & AlI
(Sec.3097,Civ.C.J.
- ADDRE55 638 Southern Ave. - � �
Lendar's Nome
�ender's add.ass arv Orange Ca 92665 7EL.N0.�7�-4} 921-OS 0
STATE 468609 uc. c-
I certify that I have read this application and state that the uCENSE NO. CLA55
above information is correct.I agree to comply with oll County
ordinances ond Siate laws relating to building construction,
and hereby authorize representatives of this County to enter
u on the above-mentioned property for inspection purposes. SEE�REVERSE FOR EXPLANATORY LANGUAGE
7-23-87
S' alure o1 Applicanl or Agent Da1e
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