HomeMy WebLinkAbout1143A (9) �
E WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT � �
� I hereby offirm that I have o cerfificate of consaM ro self '�,
I orgaf erHf ed copy�thereof(SecB3&70,LcynsCaj�o�Insurance, �6A364C NEATING - VENTILAiING - AIR CONDITIONING
CE•918(REV.10/81)
Polity No. 1021516 �ompany St3te Fund � L.d 7�'��
i � Cenified copy is hereby furnished. TR# 44824 COUNTY OF LOS ANGELES Jag# 1111 BUILDING AND SAFETY pH$ 4
i � Certi�ed copy is filed with the county building inapec- FOR APPLICANT TO FILL IN BU�L��NG
� tion depariment. ADDRESS �0751 Eas� Rim Lane
p (CRINT OR NVE ONLY)
i Dafe ']—Z3—$'] Applitant � �"�^r� IOCAUTY
8 NO. TYPE�APPLIANCE OR EQUIPMENT FEE �
CERTIFICATE OF EXEMPTION OM WORKERS' NE.4RE57
� COMPENSATION INSURANCE CRO55 57.
ABSORPTION UNIT,BTU DISTRIC7 NO. VROCESSED BY
¢ (This wcNon naad�rot ba compleiad if tho worl�in�olvod by
fh�pormif i�for oM hundrad dol{ws(5100)or lass.) � � �
AIR HANDLING UNIT,CFM
I cartify that in the parformance of the wak for which�his �
permit is issued,I shall not employ ony person in any manner
sa as�o become su6jec�ro rhe Workers'CompensptiOn Lows. 9O�LER,BTU APPFOVAIS DAiE INSiECTOR'S SIGNATURE
Date appliconf COMPRESSOR,BTU ROUGH � � 6v,/
NOTICE TO APPLICANT: If, after making �his Canificate of VENTILATION SYSTFM FINA�� �
Exemptio�, you should become s�bject to the Workers'
Compensmion provisions of the tabor Code,yov must forth- EVAPORA7IVE�OOLER VAlIDATION
with comply with such provisicns cr this permit sholl be
deemed revoked. FURNA�: FAU�_GRAVITY
LICENSE�CONTRACTORS DECLARATION FLOOR e�u
1 hereby affirm fhat I am licensed under provi5ions of Chapler 9 HEATER� �S�EtV�ED UNIT_
-(tommencing with Section 7000)of Division 3 of the Business � ' WA�i �
and Professions Code,and my license is i�full fwce and effect. �
I License Nvmber ��g_Lic.C4a:s s—�8 � .. a S� y
rvineWest 7-23-87 � m
-, Contmctar i Dare � - �-� 1 �i �n 0
`�i ❑ I am exempf under Set. . - �t` • •.` • `.`� W
Plan check fee d
8,&D.C.for this reason� � � � � •�s,�;�� a
oa�e PERMIT ISSUING FEE� 10 50 � , �.�..� = z
Signature TOTAI fEE 'rj" (p �, ��_q 7 �
-OWNER-BUILDER�ECLARATION PLAN CHECK APPLICAN7
- I here6y affirm that 1 am exempt from ihe Contracfor's Litense -�- �
' Law for the following reason(Secrion 7031.5, 8us��esc ond N.4nnE
� Professions Code):
E ❑ 1, as owner of the property, or my employees with ADDRESS
� wages as,fheir sole compe�wtion,will do the work ond
� the atrudure is not intended or offered fw sale(Seciion ��ry TEL.NO.
7044,Business and P�ofessions Code). .
OWNER William Lyon Company
❑ I,as owner af fhe property,am extlusively toniracting � �
with litensed tonlraclors�o consirutt the projeci(Sec- DDRESS 19 Corporate Plaza
tion 7044,Business ond Professions Code).
CONSTRUCTION IENDING AGENCY CITY N2WpOYt Beach 92660�i.Na714) 333-3600
I hereby affirm tha�there is a construction lending agency for � '
rhe per4ormance of the work for which this permit is issued coriTRncroRlrvineSVest Atg & Air
(Sec.3097,Civ.C.).
ADDRE55 638 Southern Ave. - �
Lender's Name .
orr Orange Ca 92665 Tei.No.f 7141 921-080
lender's Addres4
�certify that I hove read this opplication and state�hat ihe ilcer�ise No. 468609 CLASS C—Z�
obove information is correct.I agree to comply with all County . � •
ordinances and Stote laws relating to building construclion,
ond hereby authorize representatives of this Co�niy to enter
up the above-menti ed properiy for inspection pu�poses. SEE REVERSE FOR EXPLANATORY LANGUAGE
7-23-87
�ig �ure ol Applimnf or Agent - Dale �
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