HomeMy WebLinkAbout1147A WORKERS'COMPENSATION DECLARATION APPLICATIOM FOR PERMIT �
I hereby affirm that 1 have a certificate of consent ro self .
insu�e,or a cerrificate of Workers'Compensation Insurance, HEATING • VENTILATING • AIR C�NDITIONING
or a certified copy thereof(Sec.3800,Lab.C.) ����
- CE-818(REV.10/81)
�P❑olicyNo. 1O21S16 Compony State Fund - L.u�'�/,3
Certified copy is hereby furnished. TR# 44824 COUNTY OF LOS ANGELES JOB# 1111 BUILDING AND SAFETY PH# 4
� Cer��ed copy is filed with the counry building inspec- FOR APPLICANT TO FILL IN BUIIDING
tian deparfinent. � (GRINT OR TYPE ONIY) nooa�ss 20731 East Rim Lnae
Date 7-23-87 APPticont � tOCAtITv xdIROR Bdr �
NO. 7YPE OF APPLIANCE OR EQUIPMEM FEE
� CERTIFICATE OF EXEMPTION M WORKERS' NenReSr
COMPENSATION INSURAN[E CROSS ST.
(Th{s sectlon n�d not 6o complri�d if th�work inrolvod by ABSORPTION UNIT,BTU Oi57RiCi NO. PROCESSE�BY
tha parmll is for onr hu�red dolfon[SIDO�or leu.) AIR HANDIING UNIT,CFM � � �
I certify Ihat in the performance of fhe work for which this /
permit is issued,I shall not employ any person in any manner gp��ER,BTU
ao as to become subject to the Workers'Compensa}ion Laws. aPvaOvniS oate INSPECIOR'S S�GNATVRE
1 COMPRESSOR,8TU 4H�OOO ZO OO ROUGH
-Dote /+pplicant � �y
. NOTICE TO APPLICANT: �f, after making fhis Certifica�e of VEN7IWTION SVStEM FlNnI 8
Exemplion, you should become subjett to the Workers'
CompansoGon provisions of the ta6or Code,yo�must fwth- evo,voRv,nve cooteR VALIDATlON
with comply with such provisions or this permit shall be
deemed revoked. 1 FUNNA(F: FAU—G�'I��_ 10 Q�
LICENSED CONTRACTORS DECLARATION FLOOR BTU �
I hereby affirm thot I om licensed under provisians of Chapie�9 �T�: SUSPENDED UNIT_
��wmmencing with Section 7000)of Oivision 3 of the Business ` WA��
aod Profeuiom Code,and my license is in full force and effect. �� ��LETS & OULETS e� �
' 468609 c-20 � �
License Number Lic-Class , V
Zrvinewest 7-23-87 �
Contractor �ate �
H
� I am exempt under Sac �
Plan check tee �� � ���,, �
B.BP.C.for this reason .
PERMIT ISSUING FEE� �. . s � .;a
oate:
Siqnature TOTAL FEE (�C� ! . :w.`�.�J
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ��
i hereby atfirm that I om exempi from the Contracror's license � � ` `� � n?'
law ior the following reason(Section 7031.5, Business and NAME
Profassions Code): .
❑ I, as owner of the propeNy, or my employeas with /�oRE55 � G"'�G�—�7
wages as their sole compensation,will do�he work and ��n, 7Ei.NO.
ihe siructure is not inranded or offered for sole(Section
7044,Business and Professions Code�. OWNER v�illiam Lyon�Company
❑ I,os owner of the property,am exdusively coniracting ��� OT OI'8�B dZ2
with licensed mniractors to construd fhe projecl(Sea A
tion 7044,8usiness and Professions Cade). AD�RESS _
CONSTRUCTION LENDING AGENCY ��T� ewpor 0flC �F
I he�eby affirm that fhere is a consiruction landing agency for � ► -
ihe performance of ihe work for which this permit is issued CONTRAC`fORILVlIleLVCSt. HtCJ 6 A1T
(Sec.3097,Civ.C.).
ADDRESS 638 Southern Ave.
Lender's Name
oTv Orange Ca 92665 �i Np(714 —
Lender's Address
STATE LIC. C—
i certify thol�have read Ihis ppplication ond s�afe thot the tICENSE NO. � CLA55
above information is correcl.I agree to comply with all County
ordinances and Stare laws relating to building consir�dion, . �
and hereby authoiize representalives of this County to enter
upon the above-men�oned property for inspeclion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
7-23—
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