HomeMy WebLinkAbout1148A (7) WORKERS'COMP€NSATIONDEClARA710N qppLlCATlOId FOR PERMIT 11
i hereby affirm that I have a certificaie of consent to self fy
insure,or a cenificate of Workers'Compensation Insurance, ,bAx�c � HEATING - VENiILATING - AIR CONDITIONING
or a certified copy thereof(Sec.38W,Lob.C.) .
Polic No. 1(121 S l 6 �-BIB(REV.10lBI)
❑ v Compony 5tate Fund . . �c#�
Certified copy is he�eby 5u�nished. TR$ 44824 COUNTY OF LOS ANGELES ,70B# 1111 BUILDING AND SAFETY PH$ 4
� Cerl�Cied copy is filed w�th the county building inspec- FOR APPLICANT TO FILI IN BUILDING
tion deparfinenL � ADORE55
�PRINT OR TYGE ONLY) Il 2 .
Dote 7—�-�—'�7 APAlicant . �
�a'4��TY Diamond�Bar
NO. TyPE.OF APPLIANCE OR EOUIPMENT FEE
CERTIFICATE OF EXEMPTIO ROM WORKERS' NeaReST
COMPENSATIQN INSURANCE CRO55 ST. '
(ihl�soclion nwd not bo complaiod if tfw work inrolvad b AgSORPTION 11N1T,BTU
Y DISiRICT NO. PROCESSED BV
IM p��mN is for anv h�ndrod dollars(5100)or{qt.) � � �
1 certify that in Ihe performence of 1he work for which Ihis AIR HANDLING UNI7,CFM
permit is iuued,I shal!nol emp(oy any person in ony monner � �
so os to become wbjecf to ihe Workers'Compensotion Lows. BOILER,BTU APpppVAlS DATe IN57EQOR'S SIGNAiURE
Dale - eppliCant CQMPRESSOR,B7U ZO OO ROUGH ���
NOTICE TO APPLICANT: If, after making this Certificate of VENT�LATION SYSTEM ptJP,t 7��
Exemption, yo� shauld become subjett ro rhe Workeri 4
Compensptran provisions of the Labor Code,you mosl forth- EVAPORATIVE COOLER �//\���aT�O(�
wilh comply with such provisions or this permit shall be
deemed re�uked. fURNAGE Fnu�_GRAViTY
LICENSE�CONTRACTORS�ECLARATION FLOOR eiU 10
I hereby nHirm IFwt 1 am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIt_
�(commencing with Section 7000)of Division 3 of the Business � wAtt
and Professions Code,ond my ticense is in fvll for[e and affect. 7,
O.
License Nomber��ic Closs s�g , v
vineWest 7-23-87
Contractor I= Dote �
D °
I am exempt�nder Sec.
6.&P.C.for this reasan� P�an checl[fee �
oate:
PERMIT ISSWNG FEE S
?0 50 �111�8A x
Sigrwture TOTAL FEE y� � • • a a •r. 1
OWNER-BUIIDER DECLARATION PLAN CHECK APPLICANT � p ��,�;n r,
I hereby affirm lbat I am exempi fwm the Contracfor's License ' �'
Law for the following reason(Seuion 7031.5, B�siness and NqhtE � � ; �4,�' 1,,�s
Professions Cade): � �
❑ I, as owner of the property, or my empioyees with AWRE55 �'i,Q�—G 7
wages as their so(e compensotion,will do ihe wo�k ond CITY
the struUure is not intended or offered tor sole(Section TEL NQ .
T044,Business and Pro{essions Code).
OWNER william Lyon Company
❑ 1,os owner of the property,om ezclusively controcring
with licensed controclors lo mns�rvct 1he projecf(Seo- MA�� ].9 CorQorate P aza
tion 7044,Bus�ness and Rofessions Cade). ADDRESS
CONSiRUCTION LENDlNG AGENCY ��Ty Newport BeaC .. _ —
I bereby affirm thm there is o construction lending ogency for � � S
ihe performance of the work for which Ihis permif is issued �ONTRACTOHIrV�II2LYE5t Ht�J & A1T
(Sec.3097,Civ.C.�.
� ADDRE55 638 Southern Ave. - � . .
Lender':Name - - �
CITY Oranqe Ca.92665 TEL.N0.(714) 921-08
Lender's Address
srarE 468609 uc. c-
I cer�ify that I hvve reod ihis applicotion and sto�e iha�the t�CEnISE NO. CtASS
abave informa�ion is correct.I agree fo comply with all County
ordinonces and State lows rela�ing ro 6uilding construction, �
and here6y authorize�epreSentatives of ihis CouMy to enter
u on the abo�e-me tloned`property for�nspection porposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�� 7-23—g
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