HomeMy WebLinkAbout1172A (9) WORKERS'COMPENSATIONDECLARATION qpp��CqTIpN FOR PERMIT �
I hereby affirm �hat I have a cerfificate of consent to self
insure,or a certificale of Workers'Compensation InsurpnCe, ���� HEATING - VENTILATING - AIR CONDIT{ONING
or a certified copy thereof(Sec.3800,Lab.C.) CE-8tB(REV.t0l81)
POolicy No. i n�i si ti Company Gta F+nd COUNTY OF LOS ANGELES BUILDING AN�FETY
Certified copy is hereby furnished. TR# 44824 JOB# 1111 PH� 4
� CerijXjed copy is filed with�ha county building inspec- FOR APPLICANT TO FILL IN euaoiNG
lion department. (PRIM OR TVPE ONIY) ADDRE55
Date 7 ��,��APPlicant , -- LOCnuTY
NO. TYPE OF AP7LIANCE OR EQUIPMENT FEE Diamond Bar
CERTIFICATE OF EXEMPTION F M WORKERS' NEnRESi
COMPENSATION INS RANCE � CRO55 S7.
(Tbis�aeT(on nead nof ba eomplofpd if Tlw work Involra!by� ABSORPTIDN UNIT,BTU o�sTu�cr No. vaocesseo ev
Tho parmif Is for ona hundnd dollan(5100)or loss.) � /'j„„ �
I certify that in the performante of the work for which this AIR HANDLING UNIT,GFM /►�
permit is issued,I shall not employ any person in ony manne� gpILER,BTU
so os to become subjecr to the Workers'Compensot�on Laws. arvaovais onre INSPECTOR'S$iGNATURE
Dore opplicanr 1 COMFRESSOR,8TU 48,000 10 �0 ROVGH
NOTICE TO APPLICANT: If, after moking this Certificate of VENTIIATION SYSTEM FINAL �
Exemption, you sho�ld 6emme subjetl to the Workers'
Compenwlion provisions of the lobor Code,�you must forth- EV0.PORATIVE COOLER VALIDATION
with tomply with suth provisions or this permit shall 6e
deemed revoked. PURNACE: FAU—G�y ITk�
LICENSED CONTRACTORS DECLARATION 1 FLOOR B7U yV•VVV lO OO
f hereby affirm that I am litensed under provfsions of Chopter 9 HEA7ER: SUSPENDE� UNIT_
-(commendnq with Section 7000)of Division 3 of the B�siness � WA«
and Profeuions Code,and my license is in tull force and effect. }, � � � � >
INLETS & �ULETS d
Litense Number 468609 ���.Class c-2Q 7 �
irvinewest 7-23-87 � O
Contr«ror Dale
� I om exempt under Sec. . �
Plan check fee
8.8P.C.for this reason �d'if
PERMIT ISSUING FEE S �0 50 Z
Date:
Signar�re TOTAL FEE �j",�j' ` � � ^.,-„
OWNER-BUII�ERDECIARATION � PLANCnECKnrPUCnnIT . �* ` `.° ` °"� �
I hereby affirm thai I am exempt from the Contrac�or's License � � + a 6 {��
Law for the following reason (Secrion 7031.5, Business and NAME � "�'
Professions Code): ' • � .. .. ,.
❑ I, as owner of�he properly, or my employees with ADDRESS „ `, -� � 1
wages as lheir sole compensation,will do the work and ����"`� "7
the strocW�e is not intended or offared for sole(Sedion CITY TEt.NO.
704d,Business and Professions Code). �
OWNER William Lyon Company
❑ I,as owner of the property,am exclusively contracfing .
with licensed coniraciors to const�ucf ihe�projeci(Sec- DDRE55 19 Corporate Plaza .
tion 7044,Business and Professions Code). �
CONSTRUCTION.LENDING AGENCY ��Ty Newport Seach 92660rE�.Na.714) 833-3600
�here6y affirm that there is a construcfion lending agency for � .
ihe performance of the work for which ihis permit is issued CONTRACrORjrV1IlE'W25t HtcJ & A7.I'
(Sec.3097,Civ.C.�. .
ADDRESS 638 Southern Ave. ' �
Lender's Nome
aTr Orange Ca 92665 re�.r.ro.(714) 921-08
Lender's Address
I cerlif ihat I have read this a lication and stole ihot the STATE 468609 - ���� e-20
y Pp LICENSE NO. CU155
above information is mrrect.I agree to mmply with all County
ordinances and State lows relating to 6uilding constradion,
and hereby authorize representalives af this County to enter
upon�he above-me tioned property for inspenion purposes. SEE REVERSE FOB EXPLANATORY LANGUAGE
� 7-23-87
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