HomeMy WebLinkAbout1149A (7) � WORKERS'COMPENSATION DECLARATION �ppLiCATION FOR PERMIT �
I hereby affirm ihat I have a certifitate of consent to self
insure,or a certificate of Workers'Compensat�on Insu.ance, HEATING • VENTILATING - AIR CONDITIONING
o�a certified copy ihereof(Sec.3800,tab.C.) ��`�
CE-81B(REV.10/81)
POolicyNo. 1021516 Company State Fund /.6i��s
Certitied copy is hereby furnished. TR# 44824 ��UNTY OF LOS ANGELES JOB# 1111 BUILDING AND SAFETY pH# 4
� Cert�iYied copy is filed with�he caunty building inspeo FOR APPLICANT TO FILL IN 6uiLDiNG
1io�deparfinent. (PRINT OR TYPE ONLY) A�DRESS
Da�e �-��-s� Applicont _ LOCP.tITY Diamond Bar
NO. TYPE Of APPLIANCE OR EQUIPMEN7 � FEE
CERTIFICATE OF EXEMPTION M WORKERS' NEnRESi
COMPENSATION INS RANCE caoss 57. �
(Thla soction nood not bo complolod li Tha work i�volv�d b� ABSORPTION UNIT,B?U �ISTRICT NO. PROCESSEO BY
tho pormif Is!or ono hundrad dollars(i100)or Ins.) qIR HANDLING UNIT,CFM �- !� �-�
I certify ihat in the performance o4 fhe work for which this
permit is issued,1 ahall no�employ any person in any manner
so as fo become su6jed to the Wo�kers'Compensotion Laws. BOILER,BTU qCPROVALS DAiE iN5PEC70R'S SIGNATURE
Date app�i�o�� 1 COMPRESSOR,BTII 4s�OOO LO OO �UGM
NOTICE TO APPlICANT: If, afler making this Certificate of VENTiV TiON SvSTEM FINAt� �`�
Exemp�ion, you sho�id become subject to the Workers' �
Compenmtion provisiOns of the Lobor Code,you mu:t fvrlh- EVAPORATIVE COOLER VALIDATION
with comply�wi�h suth provisions or this permit shall be
deemed revoked. 1 Fl1RNACE: FAU-G��I��_ 10 00
LICENSE�CONTRACTORS DEQARATION FLOOR BTU
- I heraby affirm tiqt I am litensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT_
'(commencing with Section 7000)of pivision 3 of the 8usiness - WAtI �
and Professiona Code,and my license ie in fvll force and effect. A INLETS & OULETS � d
468609 c-20 v �
License Number lic.Class - � V
IrvineWest 7-23-87 �
Coniwctor Date Fu
❑ I am exempt under Sec. `�� � " y� ui
Plon check fee 10 50 �� � � � �p Z
8.8P.C.tor rhis reason pERM1T ISSUING PEE S
Dote:
$igrwWre TOTAL FEE . I ` `i'i''''i'�_ �
OWNER-BUILDER DECLARATION PIAN CHECK APPLICANT � � `' � - ` -
I hereby affirm thot I am exempt from ihe ContraUor's License � ��v�_R•'�
Law for the following reason(Section 7031.5, Business and NAME
Professions Code):
❑ 1, as owner of the property, or my employees with ADDRESS
wages as their sole campensation,will do the work and
the struUure�s not intended or offered for sale(Section CITY iEL No. -
7044,8�siness and Professions Code�. OWNER. ti�111118T(t LyOri C011lpdriy
❑ i,os owne�of ihe property,am exclusively conlracting
with litensed mntrocfors to construd ihe projed(Sec- ��� Corporate dZd
�ion 7044,B�siness and Professions Code). aoDRE55 _
CONSTRUCTION LENDING AGENCY ��TY ewpor 2dC TEi.N .
I hereby affirm that there is a construction lending agency for ►
the performance of the work for which this permit is iss�ed CONTRACTORII'ViI10W0St Htcj & A1I ��
(Sec.3097,Civ.C.). . .
A�DRE55 638 Southern Ave. . � -
Lender's Name
ciTv Oranqe Ca 92665 TE�.No f 714) 921—OS
Lender's Address
STATE LIC. C� �
I certify ihat I have read this appliwtion and state that the IICENSE NO. CLA55 -
a6ove information is correct.I agree lo comply with all County
ordinontes and$fate laws relating lo building construction,
ond hereby aufhorize represantarives of this County to enter
u on the above-me ioned prope�ty io.i�spection purposes. SEE REVERSE FOR EXPIANATORY LANGUAGE
7-23-87
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