HomeMy WebLinkAbout1144A (9) WORKERS'COMPENSAT�ONDECLARATION � APP��CATION rOR PERMIT �
I hereby affirm thal I have a certificate of consenf Io self R
insure,or a certificate of Wo.ke�s'Compenso�ion Insuronce, ��� HEATING - VENTILATING - AIR CQNDITIONING
or a certified copy Ihereof(Sec.3800,Lab.C.)
CE-818(REV.10/81) �
P❑ol1cy No. 1021516 Company State Fund �.pt�V
Gertified copy is hereby f�rnished, TR� 44824 COUNTY OF LOS ANGELES JOB# 1111 BUILDING AND SAFETY pg# 4
� Certi�ed ropy is filed with the co�my building inspeo- FOR APPLICANT TO FILL IN BUILDWG
tion department.
�PRINT OR TYPE ONLY) ADDRE55 z�745 East Rir.i Lane
DofC 7—�"i—R7 Applicanf �OCa'��7Y Diamond Bar
NQ. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION F M WORKERS' NEAREST
COMPENSATION INSURANCE CROSS 5T.
(This f«fion naod not 6a aom lofod if fhe work involvtd b ABSORPTION UNIT,BTl1
P Y DISTRICT NO. PROCESSED BY
tha parmil b br a.N hundnd dollar�(5100)o�bss.) �} � I '
I certify thot in fhe performonce of ihe work for which this AiR HANDLING UNIT,CFM d`— (' r
'V
permit is issued,l shall not employ any person in any manner •
so os to becoma subjed�o the Workers'COl17pE115tltlOn�aWs. 001tER,BTU .qv�ROVALS oqre �NSPFQOF'S SIGNAfURE
Dale Applicanl COMPRESSOR,BTU LO OO ROUGH
NOTICE TO APPLICANT: If, after making tbis Certificaie of VENTIIATION SYSTFM FlNAL (,�
EsempTion, you should bacome s�bjecf lo the Workers'
Compensotion provisions of the labor Code,you musf forih- EVqppppTNE COOIER VALIDqTION
with comply wilh s�ch provisions or this permil shall be �
deemed revolced. FURNACE: FAU_y_GRAVITY
LICENSED CONTRACTORS DECLARATION ROOti BTU
I here6y offirm thai I om ficensed under provisions of Chapfer 9 HEATER: SUSPENDED UNiT_
'(commancing wilh Settion 700p)of�ivision 3 of the Business Wn4
and P.ofeuions Code,and my license is in full force and eHeci. & OULETS �� '� �
�� a.
license Number 468609 ��� Class c�20 , v
IrvineWest 7-23-87 �
Contracfor Date O
� u
I am exempt vnder Sec.
Plan check fee �+
8.8P.C.for this reason ],Q 50 `� � ����' �
Date:
PERMIT ISSUING FEE; �• • e � •R. ?
Signawre TOTAL PEE y.
OWNER-BUIL�ER DECLARATION PIAN CHECK ACPIICANi -� � ����i�,�1
I hereby affirm tha�I am exempt ftom Ihe Controctar's Litense � ♦ ,-. e � .� ^ ^
Law for fke following reason(Section 7031.5, Business and Nqt�nE ` ,,7�,%��_.Q,7�`'
Professions Code): �
❑ 1, os owner of Ihe properly, or my employeas with AO�RE55
wa9es as their sole compensatian,will do ihe wark and CITY
the structure is not intended or offored for sale(Sectian � TEt.NO. -
7044,Bosiness and Professions Code).
OWNER William Lyon Company
❑ I,os owner of the property,om ezclusively conlracting
with licensed coniroctors to conslruct the prajed(Seo- M'41L 19 Corporate P aza
tion 7(1d4,Business and Professions Code). ADDRESS
CONSTRUCiION LENDING AGENCY ��N N2WpOTt II2dC EL.N .
1 hereby offirm thabihere is a conslruttion lending ogenty for ,
the performance of ihe work for which ihis permii is issued CONTRACTOR ITVlI10W@3t HtLJ & AiT
(Sec.3097,Civ.C.). �
P.�DRE55 638 Southern Ave. �
Lender's Name -
Lender's Address CITv Orange Ca 92665 iEt.NO.�7�-4� 921-08 0
I certif Ihat I have read this a licotion and sta�e thot Ihe STATE 46860 uC. C-20 .
Y PP LICENSE NO. CLASS
abova information is correci.I agree to comply with all County
ordinancea and Stafe lows relating to huilding construUion,
and hereby authorize represematives of ihis Coumy to enter
�po�rhe o6ove;m, tioned propeny for inspection p�rposes. SEE REVERSE FON EXPLANATpRY LANGUAGE
- _ ;� ' — � 7-23-87
��•---
norure of Applimnl or Aqent Date
'^ -C Q�� ' �n G .�� � �..!_ d� �.� .
�o _'L� � o .�. •3 m 'a °a�' o o � � c ��1--.'o' `o m o � o
u o ;�-c y ,� .p o.c� � �� . � a'^ a c �_ " �o � n,� c . .
° � � E--o °ia` mw � '� o ° � ovo '' o- oo � o
� c c °' ° °1 � 'i�,v�= .c..c o u ao • o v aU ci? '
Z u •° � v ��� m o c ° � > �,�F ° o c v a�-� �' s o o �a
� °� m • ' a o o E � o c �:. r. v . �i � � c d � i; '- �
F ry, 00N Em � '-° m � o � 3w , $ '� o x ' Gcow
� � c ti £'^� d`�' .� °o'�'—�� �°o o�° ° °'o i o E c o 0 3 � i
Q o o � ; o� a � � � .. m — �U � a aL m � �, a � � c ro �
J '�' � C L .� r� O � :J L � N 6 C. � � � �YI � C_ .
u a `' Q � o . m � � c m E `� o ° � ° '' c� a ` � Q ° �"� �
p � o,-� ° � d o a�- y K Q O1 ° ��' a��' �a � a � �� o o I
� a 3 p ` C.c�U ° m c ° c° ° °o U.+ � � °'° y a "o o� V^ '
v _ a� � "� x ° o a-o � o c �s ° .� ° a
0 �° ,� N a� � a� ' o �.a a o o_c� ^ s c a o '- c_' v c �
o,c c � ai � a o � a— s cv c a` " v uT � � o o � c
� _ o o �� m � � � � � w c > � 3 a� �.- � c c� u � cn v I .
� o L '.� O U C N >t X � C o c O � 2��-p� � �� h p p b � � `' •
�= � � � ; �..� � c o o �' o-w a� o �,-° E o m N� o "� "''o a� =' _o
L �. C C G` ..� [ V;
Z E�a E � `� �°�� °a 3 � � � a..� •� 3 � o ." N o E 3'` ' �
�y ..`_ ? v � c a w � o °W' c.' �; c _ m v �= ° c �' . r �� o „ o a I
C �O b L-� O O U O 0 O „ N �V ❑ m N in U U � O
O a J o a � w o �� ° >. oa , � v c� o E •� ° �� 'v'c-o "' ° � � ,
>. � .c o o .o — i, v w �a �_v_ ` v d - o x
v � d �' na N� o o u F ,n � m�.� �o U L s a o � .� � �,o U� `a o � a i N
U d � � t �'C C � C _ O` w li vi p� � C J] G .� vi �,t V � 81 C .
r � � d� � �' owo�oao ma� �.c o `i3o o � �-� N " o °� a 3
� m o o-E U in M i. � a s '� 0 3 3 � E o c ,� cn o 3 t. — m p O
' s
H
H
�
Y!
�
0
G -
�
z
N
W
' . . 0
; z
h
OG
0
G
W
6.
N
Z
`. _ . �
�