HomeMy WebLinkAbout1170A (9) WORKERS'COMPENSATION DECLARATION APPLiCATlOM FOR PERMIT �
I here6y affirm that I Fwve a certifica�e of consent to self
insure,or a certificate of Workers'Compensotion�nsurance, 76A�� HEATING - VENTILATING • AIR CONDITIONING
or a certified wpy thereof(Sec.3800,lab.C.) CE-818(REV.10/81)
p❑ol'�cy No. i n���_c�c ComP�^Y SY.1t6 Ftttl(� ���
Cerrified copy is hereby fu�nished. TR$ 44824 �OUNTY OF LOS ANGELES JOS# 1111 BUILDING AND SAFETY pg# 4
Cert''ed copy is filed with}he tounty building inspec- FOR APPLICANT TO FILL IN eUItD�NG
f�on�eparfinenf. (PRINT OR TYPE ONIY) ADDRE55 20752 East Rim Lane
Dote ApplitaM �a„iirr Diamond Bar
�- NO. TVPE OF APPLIANC�OR EQUIPMEN7 FEE .
CERTIFICATE OF EXEMPTION OM WORKERS' NFAREST
COMPENSATION INSURANCE CRO55 S7.
(Th{s s�cTion�wed nof bo eomplalad if tha work lnvolwd 6y ABSORPTION UNIT,BTU OISTNiCT NO. PROCESSED BY
the pormif is for on�hundr�d dollus(�100)or lau.) �"1 � � ), �_
AIR HANDIING UNIT,CFM
I certify that in the perform6nca�of the work for which lhis d �/j/
permit is issued,I shall not employ any person in any manner �
so as to become wbject ro the Workers'Compensation Laws. BOILER,BTU APPROVALS DAIE MSPECiOR'S SIGNATl1RE
1 connveEssoa,aru 48,000 10 �0 ROUGH � •
Date Applicant .
NOTICE TO APPLICANT: If, after making ihis Certificate of � VENTIIATION SYSTEM FlNaL
Exemptlon, you should become subject to the Warkeri
Compensation provisions of the lobor Code,you musf forfh- EVAPORA7IVE COOLER VAIIDATION
wilh comply with such provisions or this permir shall be
deamed revoked. . 1 fu00R�� FAU BT� G��T�— 10 00
LICENSED CONTRACTORS DECLARATION
I hereby affirm thai!am licensed under provisions o4 Chapter 9 NEATER: SUSPENDED UNIT_
'(commancing with Section 7000)of Oivision 3 of the Business ' �'A«
and Professions Code,and my iicense is in fuii force and effect. �/ � �
N INLETS fi OULETS p �
License Num6er 468609 L�c Class C-20 � V
IrvineWest 7-23-87 • °C
Contractor Date. �
H
� �am exempt under Sec. W
Plan check fee d- �
B.BP.C.for this reasan :�-� i /.i.i� �
PERMIT ISSUING FEE S 10 50
Date: ji . o e • .n
T�TAL FEE
�;S
Signature � � • •J 3,��•.I
OWNER-BUILDER DECLARATION FL4N GiECK APPLICANT �� { - ;..
1 hereby offirm Ihat I am exampt from Ihe Contractoi s license � �� ��� "
law for the fa�lowing reoson (Section 7031.5, Business and NAME � �
� .. 1;� - ,
Professions Code):
❑ I, as owner of the property, or my employees with
ADDRE55
wages as their sole wmpensation,will do the work and CI7Y TEI.NO.
the shucture is not intended or offeied far wle(Section
� 7044,B�siness and Professions Gode). OWNER william Lyon Company
❑ I,as owner of ihe property,am exclusively tontracting MA`
wi�h licensed contrattors�o construcl Ihe project(Seo ].9 COYPOLdte P1dZd
fion 7044,Business and Professions Code). ADDRE55
, CONSTRUCTION LEN�ING AGENCY �iTv NeSvpOrt Beach 92660rE�,�,714? 833-360
I hereby affirm that there is a consiruction lending agency for ►
the performance of the work for which ihis permit is issued CONTRACTORIYV1ReWESt HtCJ & Air
� (Sec.3097,Civ.C.�. .
�ooREss 638 Southern Ave.
Lender's Name
uTv Orange Ca 92665 rE�.No.(714) 921-08 0
Lender's Address
I cer�ify thot I have read ihis application and state ihat ihe SCENs�No. 468609 ��� C-20
above information is correct.I agree to comply with all County . .
ordinances and State laws relating�o building consiruc�ion,
and hereby au�horize representatives of this Counly to enter
upon the above-mentiqned proper�y fo.inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �
� 7-23-87
S" owra of Applicont or Agen1 Da�e � �
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