HomeMy WebLinkAbout1145A � � WORKERS'COMPENSATION DECLARATION ' �
I hereby affirm�hat I have a cartificare of consent to self APPLlCATION FOR PEP.MIT
insure,or o certificote of Workers'Compensation Insurance, ���� HEATING - VENTILATING • AIR CONDITIONING
or a certified copy thereof($ec.3800,Lab.C.)
CE-818(REV.10�81) �.,_r. �[
Polity No.��Compony Stiatp $y7Ad � � �iJ7�/�/
❑ Certified copy is hereby furnished. TR# 44824 COUNTY OF LOS ANGELES JOB# 1111 BUILDING AND SAFETY PH�r 4
� Cerr�ed copy is filed with the couniy build�ng inspec- FdR APPLICANT TO FILL IN euILDING
tion deparlment. ADDRESS 2�739 East Rim Lan�
(PRINT OR TYPE ONLY�
Dme�z���.:r_APPlicant - . LOCauir
NO. TYPE OF APRIANCE OR EQUIPMENT FEE
CERTIFICAiE OF FJCEMPiION M WORKERS' taEqRESr
COMPENSATION IN RANCE . CRoss 57. �
. (This wclion naod no}6a eomplat�d if Ih�work Inrolrod by ABSORGTION UNIT,BTU �ISiRICT NO. PROCFSSFD BY
tho porm4l is ior ono hundrod dollnrs(SIW)or lo�s.) qIR HANDLING UNIT,CFM �„^ W1�(_ !�� -
i certify that in ihe performance of the work for which this i i� ��l f
permif is issued,I shall not emplay ony person in any manner gpILER,BTU
so as ro became subjecr to the Workers'Compensation Laws. nPrRovnis DATE MSPECTOR'S SIGNATURE
Da�e /+pplicont COMPRESSOR,BTU ROUGH �
NOTICE TO APPLICANT: If, after making this Certifiwre of vEN71LAnON SvSTEM FtNnt 2�
Exemption, yo� shovid become s�bject to ihe Workers'
Compenwtion provisions of the Lobot Code,you must forfh- EVAPORAiIVE COOLER VALIDATION
with compty wifh such provisions or this permH sholt 6e
deemed revoked. FURNACE: FAU x GRAVITY
UCENSED CONTRACTORS DECtARATION . 1 FtOOa BTU 90�Ob� 10 OO
I hereby affirm that I am licensed under provisions of Chopter 9 SUSPEnIDED UNI7_
-(commencing wifh Section 700D)af Division 3 ot the Business HEATER: WA��
and Professions Code,ond my license is in fuit force ond effecr. �71 �
d INLETS & OULETS �? J" 0
License Number 468509 ���,Class c-20 � V
IrvineWest 7-23-87 �
Controctor Date ��!I � Q-�N O
� I am exempt under Sec. V
Plan check fee ��. . . . .g d
8.8P.C.for this reason . � w
PERMIT ISSWNG FEE S 10 50 I � �a'�G G �
Dote:
Signature TOTAL FEE (w � „ + ;..,v,? �
OWNER-BUILDER DECWRATION PLAN CHECK APPIICANT
� nz_�
I hereby a4firm thot I am eaemp�from ihe Comracloi s License � (l Ci.�.. O
law for the following reason �Section 7037.5, Business and NAME
Professions Code): . -
❑ I, as owner of fhe property, or my employees wirh ADDRE55 ,
� wagesns their sole compenso�ion,wfll do the work ond -
the stroctvre is nol iniended or offered for wle($ection Citt TEL NO.
704a,Bus��ess and Profession:Code}.
OWN�R yVilliam Lyon Company
❑ I,as owner of Ihe property,om exclusively controcting
wilh licensed contrqctors to construct fhe projecl(Seo- DDRE55 19 Corporate PIdZd
lion 7044,Business and Professions Code).
. CONSTRUCTION IENDING AGENCY CITY N2Wj�Ort Beach 92660rei.N�.714) 833-3600
I hereby affirm thai there is a consrruction lending agency for �
� the performance of the work for which this permit is issued coNTancroRirvinewest Ht & A1T
(Sec.3097,Civ.C.}. .
� nooaess 638 Southern Ave.
'� lender's Name .
nrv Orange Ca 92665 rE�.No.(714) 921-080 .
lander's Address
I certify thal I have read this opplicotion and state that the. SC�NSE NO. 468609 ��� C-2�
above infwmation is correct.I agree to tomply with all Couny � �
ordinontes and$fate laws reloting to building mnstrudion, . . . �
and hereby authorize represenla�ives of this Counly to enter �
upon ihe above-mentioned properry for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
— 7-23-87
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