HomeMy WebLinkAbout1169A (7) WORKERS'COMPENSATION DECLARATION ,qpp�,�C���OR9 FOP PEPMIT �
1 hereby affirm that I have a certificate of consent to self ♦ �
insure,or a cerfificofe of Workers'Compensation Insuronce, ���� HEATING • VENTILAiING - AIR CONDITIONlA1G
or a tertified copy ihereof(Sec.3800,La6.C.)
CE-818�REV.l0/8l�
P❑olity No. 1(121 51 6 Company State Fund �o7r�`�
Certified copy is here6y furnished. TR# 44E324 COUNTY OP LOS ANGELES JOB$ 1111 BUILDING AND SAFETYPH$ 4
� Cerp#ied copy�s filed with the coonry b�ilding inspeo- FOR APPLICANT T�FILL IN BUILDING
tion deparimenf. ADDRE55 20758 East Rim Lane
(PRINT OR TYPE ONLY)
oafe�-��-�7 Applimnt - �� LOCAUTY Diamond Bar
NO. TYPE OF APPIIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION OM WORKERS' . NenRESi
COMPENSATION INSURANCE CRO55 ST.
(This aacfion need nof be comploted if fho work involvod by AB50RPTION UNIT,BTU DISTRIC7 NO. VROCESSE�BY
Ihe pormiT is for ono hundred dollan(5100)or loac.) � � �
1 certify that in the performan[e of the wark for which this
AIR HANDIING 11Nli,CFM
permit is issued,I shall not employ any person in any manner
so as to become subject to ihe Worken'Compensarion Lows. BOILER,BTU APPROYALS DATE INSFKipR'S SIGNAiURE
pa�e APP�i�a�� j COMPRESSOR,BTU 48.000 LO OO ROUGH � � ��
NOTICE TO APPLICANL•.If, after making ihis Certificate of VENTILATIONSvSTEM FINAL �
Exemption, you ;hauld become subjetl �o the Warkers' .
Compensafion provisions o{Ihe La6or Code,you must forth- EVAPDRATIVE COOLER VALIDATION
with comply with such pravisions or this permit shal� be
deemed�evoked. FURNACE: FAU X GRAVIN
LICENSED CONTRACTpRS DECLARATION FLOOR aiU 90.0�� 10 OO
i hereby affirm ihot I am licensed under provisions of Chapier 9 SUSPENDED UNiT_
"(mmmencing with Section 700p)of Divisian 3 of the Busineu HEATER: wA��
and Profeasiona Gode,ond my{icanse is in full force ord effed. O �� � Y
�
License Number_�}�g��9 tic Class C 2n � V
Co�+.acro. Irvinewest oo�e �-23-$� °C
O
v� i am exemp�under Sec. W
Plon check fee �
6.8P.C.for ihis reasan w
PERMIT ISSUING FEE� 10 50 �
Dare:
5ignature TOTAL FEE pv `� � � f r F'
OWNER-BUILDER DKLARATION PIAN CHECK APPLICANT �' � � � ` '�
I hereby affirm that I am exemp�from the Contructor's License � � e r;�-.
Law for Ihe following reason (Section 7031.5, Business and NAME. °�`t'`"-"
Proiessions Code): � -. . „„�
❑ I, as owner of the properry, or my employees wi}h �DRESS �.`vC V_^,7 1
woges as their sole tompensalion,will do 1he woik and �
the stroctore is noi intended or offered for sale(Sedion CITY TEt.NO.
7044,Business and Professions Code).
OWNER william Lyon Company �
❑ I,os owne�of the praperty,am exclusively contratting
wiih licensed coniractors to construct ihe project(Sec- ��� � .
lio�7044,Bus�ness and Professions Code). A�DRE55 19 Corporate Pla2a
CONSTRUCTION LENDING AGENCY CITv Newport Beach 9266Qei.ivo(-714�)� 833-360 �
I hereby affirm that there is a constroction lending agency for S
Ihe performance of the work for which ihis permit is issued CONTRACTOR T �
(Sec.3oq�,a�.c.). _rvineWest Ht & Air
� A�DRESS 636 Southern Ave. � � �
Lender's Name �
Lender's Address ��T� Orange Ca 42665 rEi.No.(714) 921-08 0
I certify that I hove read ihis application and state thar tbe uT ENSE NO. 468609 c ASS C-20
above infoimation is wnect I agree to comply wilh all Co�nly
ardinances and Srate laws relating to building consiruction,
and hereby ou�horize represematives of this Counry fo enter
upon the above-m tioned property for inspection purposas. SEE REVERSE FOR EXPLANATORY LANGUAGE
7-23-8�
Si ture of Applicant or Agenf Dafe -
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