HomeMy WebLinkAbout1142A (9) WORKERS'COMPENSATION DECLARA710N APP�.{CATIOIN FOR PERMIT� - �
I hereby affhm that I have a certificate of consenr ro self
insure,or a ce�tificate of Workers'Compensation Insuronce, 7��� HEATING - VENTIIATING - AIR CONDITIONING
or a certified copy thereof(Sec.3800,Lab.C.)
CE-BI8(REV.10/81� �{,Q
POol�ity No. �n���ci.r. Comp�ny e�-�+o o.....i ��lr 1�
Certified copy is hereby furnished. TR# 44524 �OUNTY OF LOS ANGELES JO$# 1111 BUILDING AND SAFETY P�# 4
� Cert ed copy ls filed with�he county 6uiiding inspeo- FOR APPLICANT TO FILL IN BV�tDING
r�o��aparlmaM. /� ADDRESS z�757 East Rim Lnae
, — (PRINT OR TYFE ONIY) ����N Diamond Bar
Date Applicant ��-p'
�— � NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
.CERTIFICATE OF EXEMPTION� OM WORKERS' NEAREST
COMPENSATION INSURANCE CRO55 Si.
(This soctton n�ed not be compbf�d if fhe work involved by p'��RPTION UNIT,8TU DISTRICT NO. PROCESSED BY
� The permif is for on�hundred dollan(S1U0)or less.) � . r�_ -�L,...� /
I cerfify that in the performance of the work for which�his A�R HANDLING UNIT,CfM //Y ItiJ
petmit is issued,I sholl not amploy ony person in ony monner gpµ�R,8TV
so ns to become s�bject to the Workers'Compensation Laws. aaveo�nis DAlE �NSPECTOR'S SIGNATVRE
�ate Applicanl 1 COMPRESSOR,BTU �$•��� 10 �� ROl1GH 1j70,
NOTICE TO APPLICANT: If, after moking this Certificate of VENTILATION SVSTEM FINAL 'L �
Eaemption, you should become� subject to ihe Workers'
Compensation provisians of the La6or Code,you musf forth- EVAPORAT�VE CooIER VALIDATION .
with comply with such provisions or this permir sholl be
deemed re�Oked. FURNACE: FAU—G�qy ITY
�LiCENSED CONTRACTORS DECtARATiON - 1 ftOOR B7U yU•�7U� S� OO
I hereby a{firm fhpi 1 om licensed under prorisions o4 Chapter 9 - HEATER: SUSPENDED UNIT_
'(commencing wi�h Sedian 70p0)of Division 3 of the Bus�ness wAu
and Professions Code,and my licerrsa is in full#orce and effect. Ih �
� INLETS & OULETS rt � �
License Number 468609 ���.C�Qu C-20 � �
V
IrvineWest 7-23-87 �
Contractor Dare �
� �'::1 1 G 7_F 'u'
I am exempt under Sec. ul
Plan check 4ee � .`. . . �ri, y
B.BP.C.for this reason '
PERMIT ISSUING FEE S 10 50 ., z
oo�e: I � •Li�i v V
Signalure TOTAL FEE y� � . :: F/: , ; r x
OWNER-BUILDER DECLARATION PL4N CHECK APPLICANT - �r.C��'ri 7
I hereby affirm ihat I am ezemp�f*om the Conrractor's License � _
Law for the following reason(Section 7031.5,Business and NAME
Professions Code):
❑ I, as owner of the property, or my emp�oyees wifh ADDRESS
wages as fheir sole compensation,will do Ihe wo�k and , ❑TY TEL NO.
the str�ct�re is not intendad or offered for sale(Section ,
7044,Business and Prafess�ons Code): - � -
owNea William Lyon Company
❑ 1,as owner oi the property,am exclusively coniraUing
with licensed conirnclor5 fo COnstrVc�ihe projecf(Sec- ODRESS 19 Corporate Plaza
� �tion 7Q4d,$vsiness and Professions Code). -
CONSTRUCTION LENDING AGENCv ciiv Ne�vport Beach 92660rE�.N6.714) 833-3600
I hereby offirm that there is o constroction lending agenry fo. . �
ihe performance of the work for which this permit is iss�ed CONTRACTORIrV1II2ti�0St HtQ & Alr
(Set.3097,Civ.C.).
ADDRE55 . .�_ . . . . ... . . .. _..---._�_,____.
Lender's Name ' 638 Southern Ave.
��TY Orange Ca 92665 rei.No.(714') 921-08
Lender's Address
I cerlify that I have read this application and atate that the ST���. 468609 �LA� e-20 _ _
above information is correct.I agree lo comply with all County .
ordinances and State laws reldting to building conshuc�ion, .
and hereby authorize�epresentatives of fhis County to enter
u on the above-mem ned property for inspeciion purposes. SEE REVEYSE FOR EXPLANATDBY LANGUAGE
7-23-5�
, ' _.. ,. . . ., .... ..... .. . . ......
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