HomeMy WebLinkAbout1171A WORKERS'COMPENSATION DEGLARATION APPLICATIO(d FOR PERMIT �
I hereby affirm that I have a certiticate of consent to self
insu�e,or a cerrificate of Workers'Compe�sario�Insurance, �bA� NEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec.3800,Lab.C.)
CE-818�REV.10/81) � ��J'�
P❑ol'�cy No. �no�^�i G Company Stat� Fu^� i�u
Cer�ified copy is hereby furnished. TR� 44824 �OUNTY OF LOS ANGELES JOB# 1111 BUILDING AND SAFETY pH# 4
� Cer�ifl,ed copy is filed with the tounty building inspec- FOR APPLI[ANT TO FILL IN 6UIlDING
IiO�ClBpdrtmCM. �PRWT OR TYPE ONLY� A�RESS
Date�t��—Applicon� ����Tv Diamond Bar
NO. TYPE OF A�PLIANCE OR EOUIPMENT FEE ,
CERTtFICATE OF EXEMPTION F M WORKERS' - NEAREST
COMPENSATION WS ANCE CRO55 Si. -
(This s�eiion naod not 6a eomplalod if Hu woh involv�d by A��RFTiOrv UNIT,BTU oisraia rvo, rrsocesseo ar
Iho permll ia for ono bundrod dollara(5100)or Iau.) `�.�� r� r
(cerfify thot in the performpnce of Ihe work for which this AIR HANIXING UNIT,CFM � ���, ��
permit is issued,I sholf nof empioy any person in any manner gpllER,BTII
so as fo become subjecl to the Workers'Compensotion Laws. aQo � aareovn�s oa� INSPECTOR551GNATUBE
Date Appiicant COMPRESSOR,BTU ROUGH `�
NOTICE TO APPLICAN7: if, afrer making this Certifimte of VENnLnTION�5v5�Ena FINAt
Ezemption, you should become subiect fo the Workers'
Compenwtion provisions of the labor Code,you m�st forlh- EVAPORATIVE COOIER VAtIDATION
with comply with such prmisions or this pe�mi� shall be X .
deemed revoked. 1 FURNACE: FAU_G IJ'4 �
LICENSED CONTRACTORS DECLARATION FLOOR eru
I hereby affirm thal I am licensed�nder provisions of Chapter 9 HEAFER: SUSPENDED UNIT_
-(commancing with Section 70D0)af Dlvision 3 of the Business ' wA��
and Professions Code,and my license is in full force and effect. INLETS & OULETS }
468609 c-2D �� p
License Number Lic.Cbss � � Y
IrvineS7es� 7=Z3=87— �
CoMratlor pote - �
r
� I am ezempl under Sec. - � � � �
Plan check fee
8.8V.C.for this reason �
PERMIT ISSUING FFE S Z
Date: [
TOTAL FEE H�S Uc7 � � _;� } 3
Signature
OWNER-BWIDER DECLARATION. PIaN CNECK nvaliG4nl7 -
I hereby offirm ihat I om exempi from ihe Contractor's license � � • • e o o,-^�
Law for ihe following reason(Sec�ion 7031.5, Business and NAME . .
Professions Code): r y ��'�'''r�–
❑ I, as owner ol Ihe property, or my employees with ADDRESS f' '� a
L'„�,.—::�/;.
wages as Ihei�sole compensation,wlll do the work and
the sfrudure is not intended or offered for sale(Secfion CITY TEL.NO. �
7044,Business and Professions Code). OWNER 1 -
❑ I,as owner of the property,am ezclusively contracling �i
with licensed coMradors�o conslruct ihe project($ea qpDR. �
tion 7044,Business and Vrofessions Code).
CONSTRUCTION LENDING AGENCY CITY tEt.NO.
1 hereby affirm ihai there is a construction lending aqency for �
the performance of fhe work for which this permit is issued CONTRACTORITV1I12SQ0S t.eJ & , iT .
(Sec 3097,Civ.C.�. -
ADDRESS 011 . �
Lender's Name
� CITY . TEL NO. ...
Lender's Address
STATE IIC.
I certify that I have read this applimtion and stote fhat the LICENSE NO. CL45S
obove intwmation is co�recl.I agree to comply with all Counly
ordinances and State laws relating to building consiruc�ion,
ond hereby aulhorize rep�esen�arives of this County to eMer
uypn rhe abave-me dioned prope�ry fo.�nspection purposes. SEE REVERSE FOR EXPLANATORV LANGUAGE
��� _� 7-23-67
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