HomeMy WebLinkAbout1146A WORKERS'COMPENSATION�ECLARATION /;FPLICATION FOR PERMIT �
I hereby affkm that I have a terlificate of consent to self
insure,or a certiticate of VYorkers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
o�a certified copy thereof(Sec.3800,Lab.C.) �bA36a� �
CE-818(REV.10/81�
P❑olity No._j,Q,Z,.j,��Company G+a+a Fnnd ����
Certified capy is hereby f�rnished. TR� 44824 �OUNTY OF LOS ANGELES ,�pg# 1111 BUILDING AND SAFETY pH# 4
� � Cert}�ied copy is filed wirh the counry building ins ec- FOR APPLICANT TO PILL IN BUILDiNG 20735 Edst R1It1 Lane
lion deparfine��. (PRINT OR TYPE ONLY) ADDRE55
�a+e...� 33 g� Applicant ��A��TY Diamond Bar
NO. TYPE OF APPUANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION F M WORKERS' _ NEAREST
COMPENSATION INSURANCE CROSS Si.
(This soction naod not bc[omplofod if the work involved by ABSORPTION UNI7,B7U DISTRICi NO PROGFSSED BY
iha parndf is for ono hundrod dolla��(;1Q0)or bss.) � ly,_ �
� I cerlify that in the performance of the work tor which rhis AIR HAN�UNG UNIT,CFM - a��
permit is issued,I shcl�nof employ any persvn in any manner gpllER,BTU
so as to become subject to the Worke�s'Compensafion Laws. aPPrtovn�s onTe INSPEC70R"5 SIGNAiURE
Date Applicanl COMPRESSOR,BTU ROUGH
NOTICE TO APPIICANT: If, afler making this Certificate of VENTILATION SYSTEM FINAL
Exemplion, you should become su6jecl to the Workers'
Compensation provisions of the Labor Code,yau musf forth- EVAPORATIVE COOLER VA��A7�dN
with compfy wifh such provisions or ihis permit sholl be
� deemed fevoked. fURMACE: FAU_�_GRAVITY
LICENSED CONTRACTORS DKIARATION FLOOR aiu
I here6y a$irm that I am{icensed�nder provisions of Chapter 9 HEATER: SUSPENOEO 1/N1T_
-(commencing wiih Section 7000)of Division 3 of ihe Business ' �'�'A«
and Professions Code,and my license is in full force ond effect. py,
( a y s� o
License Number��li4.Ciasstiz� , V
OC
Confractor i_rvi neS'7e&t .Date �"23—s7 - ' 0
F
� �°'1 1 ^_c u�i
I am exemp�under Sec. p�an CheCk fee �a���°�!�q a
B.&P.C.for this reason e e c j�'`4•u,= Z
PERMIT ISSUING FEE S 10 50 ,_.
�ate:
TOTAL FEE
Signalure
OWNER-eU1LDER DECIARATION PLAN CHECR APPLICANT
I hereby affirm thal I am exempt from the Coniractai s License � �'� ',%�``;7
Law for the following reason (Section 7037.5, Business and NAME
Professions Code):
❑ I, os owner of ihe property, ar my employees with A��E� .
woges as Iheir sole compensarion,will do the work ond ��i� TEL.NO.
the structure is oot intended or offered for sale(Section
7044,Business and Professions Code). OWNER ti9illiam Lyon Company
❑ I,as owner of the properiy,am exclosively contracting
wifh licensed conhactors to conslruct the proiect(Sec- ��� 19 CO'_'porate PidZd
fion 7044,B�siness and Professions Code). �DRE55
� CONSTRUCTION LENDING AGENCY � ��Ty Ne47pOYt B6dCh 92660TEt.N�.714) 833-36 0
�hereby affirm rhat�here is a consirucfion lending ag.ency for ,
the performonce of�he work for which lhis permit is issued �pNTRACTORIIV1II26�725't H't�j & Aii
(Sec.3097,Civ.C.). �
ao�aess 638 Southern Ave.
Lender's Name
cirv Orange Ca 92665 TEL.NO.��14� 921-080
Lender's Address
I certif thal I hove read�his a lication and state�hat ihe StnTe 468609 ���� C-20
y pp IICENSE NO. cWss
above information is correct.I agree fo comply with all County
ordinances and State lows relating to building tonsfruction, .
and here6y outhorize represantotives of this County to enter .
u on the above- entioned property for inspection pu�poses. SEE REVERSE FOR EXPLANATQRY LANGUAGE
� � 7-23-8�
gnature of Applimnl or Agenr Date
� y V y Q7 � m�
oo3.epo� a, y � � a
� � =` l�� y ° 3 °,o° � `Z � a -c
2 oo �aa, om � �aa, moa c oi � 6 � m
r C Q b�'� � G i.�
� ,� � ° � �.°'y r c�o.,-r,�', `� � o o ,� ` c � �, o a• b � � o
Q y p O p d O � n b y � � V Q N 0`0 � ,C � 'o' � �,ti0
� o c ~,£�y= 4 o m E�O w`' -c°~ ° �oc-o��c ' a ° ° � � I
u a u �y; o�-c a �'a, :o�;,c 'C o ai � i �� � e',�,?r r o c ` '
4 � � o '' o ` m v � ., � -b o o a � . ° � o x ` '` � $ Q
O� X °'�• ° ` � °'�� � � � 3 c� (� c r ° �a °,� u . �; � o � •
� � '� o i, 0 4� a�. Q� °' E :�.�' c o � E�' o �� o o ° 0 3 �
� �C o v � ��r h s o c Q v`o ° � o m ° i�« v � e�,
'� � O C C �y a4`� k p L C O O 9i 4.l J � 07 a 4 � G p� D� '
.G; Q 0 N O J,O fj a 'O '�n 4.. � y N � �'�' ' �,Q 4 O O h�. G �L . .
tL� .0�`y � i� h -'� y � C X -c b a O O� C 4 � u v?� Q � O .
Z Eo Q '' � o °' �ps a �o � c � ,�� y,c,c; m ooaa ��
3 � 4- 4 � y�� �,�� "� � °.� ymomti3 ; o -� �ap�°o �
� o � c n�¢�� ° � u o� c `o y a a a a a "' o " c � ,� o
y,b � O � b,C,a O o O>>.� • 3 c C � _F p �O� a a � y a �' h y' t
�ia, amoxcoo,o�vo a '�a ° � �� o n���3a � cm"'o� oo � � h
� � � m .. 3 a, Q-� a
.0 v n P 0 i Q D ll m'� p h a� 7 C� h � C� � O,� j b F 3 % � �
-�m' m � ao � i. c�y' �n :o � 3FaE; o °rmvox o � "
� b'F(�y �O p O �� ;ry �.I-O,G C� j�O� ` s� V N N �' t� 'C
li � C Q� Q
•� ,� oao t� _L�� � o �� C7 rno �a o° E o
` `O33cF3o � � ��v4o x
O C p y �-C U V � CJ . .
�� 3 H r o � �
o �
. _ � � c
� O
� �
i
O '
,s
�
�
i
Z
�
�
�
. �
� �
. z
H
4
- O
� w
h
Z