HomeMy WebLinkAbout1141A (9) WORKERS'COMPENSATIONDECLARATION pppLICATION FOR PERMiT
I here6y offkm that I have a cerfificate of consent to self
insure,or a certifica�e of W«kers'Compensation Insu�ance, ��� HEATING - VENTILATING - AIR CONDITIONING I�
or a certified copy ihereof(Sec.3800,Lab.C.) �_g�g(REV.10/81) !9 �I
/
P�ollcy No. ��1�1 F7 F Company St��P F��n� COUNTY OF l05 ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished. TR� 44824 JOB� 1111 PH�r 4
� �y� Cart�,ied copy is filed wifh fhe cvunty 6uilding inspec- FOR APPLICANT TO FILL IN BUILDING
�Y �;on deparlment. ADDRESS
(PRINi OR iVPE ONIY)
Date���—�_ApPlicont � • LOCAtIiv
NO. TYCE OF APPIIANCE OR EQl11PMENT FEE
CERTIFICATE Of EXEMPTION F M WORKERS' NEAREST
COMPENSATION INSURANCE CRO55 ST.
(Thls wctbn�wad nof Fw complotod if tba work involrad by AeSORPTION UNIT,BTU �ISTRIC7 NO. PROCESSED BY
fhe permif Is for o�hundred doflan(i100)er lvs�.) `�.
I certify that in ihe performance of the work for which Ihis AIR HANDLING UNIT,CFM . �1'', �-
pe�mif is iss�ed,I sholl nof employ any parsan in ony monner gp��ER,BTV
so ns to 6ecome subjetl io the Workeri Compenwtion Laws. naaeovnis OATE INSPECTpH'S S�GNATURE
1 COMPRESSOR,BTU 4H�OOQ ZO OO ROUGH
Dafe Aoplitonl .. . . . . ....
NOTICE TO APPLICANT: If, after moking ihis Certifitate of VENTILATION SYSTEM FINAL �„(F�
Exemption, you should become su6ject to the Workers'
� Compenwtion provisions of tbe lobor Cocfe,yov mvst forth- EVAPORAttvE COOLER VALIDATION
wifh comply with such provisions or this permit shall be
deemad revoked. 1 FLOOR� FAU eTu Gy�•�1�— 10 00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chap�er 9 SUSPEnIOED UNIT_
HEAiER: WALL
(cammencing with Settion 7000)of Division 3 of.the Business
ond Rofessions Code,a�my license is in f�ll force and eNecf. `t • �
7 INLfiTS & OULETS �I p
License Nomber 468609 �i�,Class c�20 , U
IrvineWest �-23-87 °0
Contractor Date =� � � � �i �
❑ I am exemp�under Sea Plon check fee '�u � � � �� �
B.&P.C.for this reason � ' °�i.�-�'�1 �
PERMIT ISSUING FEE S 10 50 �
Date: • r -�;�.:^.x
TOTAL FEE — ° 'l - �
Signature a �._p
OWNER-BWIDER DECLARATION PLAN CHECK APPLICAM �'=��" � �
I here6y affirm thal l am exempi from ihe ContraUor's License � �
Law for the following ieason(Section 7031.5, Business and NAME �
Rofessions Code)�
❑ I, os owner of ihe property, or my employees with '4��RESS
wages as Iheir sole compensation,will do the work and
Ihe strutture is not intended or offered for sale(Section CI1Y 7EL NO.
7044,Business and Proiessions Code�.
owrvEa William Lyon Compar.y
❑ 1,as owner of the property,am ezclusively contracting
with licensed contractors to constr�ct the project(Seo- ODRE55 19 CorQorate Plaza .
tion 7044,Business and P�ofessions Code).
CONSTRUCTION LENDING AGENCY CITY N2��OLt Beach 92660TEi.i.�.714? 833-3600
I hereby affirm that there is a tonstruction lending agency for ' ►
ihe performance of the work for which this permil is issued CONTRACTORITV1272W@St Htcj & Aix'
� (Sec.3097,Gv.C.j.
nooRess r�38 Southern Ave.
lender's Name
arr Orange Ca 92665 TEL.NO.(714� 921-080
lender's Address
I certify that I have read this application and state ihat ihe iicervs�No. 468609 ��A� C-20 �
above information is wrrect I agree to comply with all Co�nty .
ordinances and State lows�elating to building consrruction, . �
and hereby authorize representatives of this County to enfer � •
u on the obove-mentioned property fo�inspection pmposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
7-23-87
naturc of ApplicoN or Agent Da�e
� '
� a
\
. } o �
� �
` N� O � � d y O .
T L p O�"O V O G O p v�
V «. � G O� L ,?�'�V 4-•�- �
, � G � Q m m�O D v.� C�O O �" .
L in '.n � G"O G . O � � � j N .L-� 7 r p� Q� . . .
� } N O � �C � �V O'..�� .- 11 (y 01 p� v ` �W � 'C C
,n �j't�, m O. 3 �r m'V1 m S �i L a O m L O 7 v� � `^ O O �' t�
' 'O M 3 �O N.p C�'6 � O yi > L N~ C 7i � ` p,� D � �n � D
� o TE o m o c � c u"' m 3 o m o � o c o �
a.r �� �.N � o 0 o m � � ov o c ad o ° o = °, _a o
0 0 0 �, c '" o� m o o�L, ;�u o � E o >-�°' °" a.o m �°' n 3 � o
O sv+ ° a"� du� °' � '` Q Y"' ° �-°a, �� o m fl'Oo`. os o d � °�
4 E �� E. .�. �QP L= aa.E oo °' nr o ot,= � � odon6� � s
� �. o �;,'o�E c a- °" o c a�d o t � i° o-o �, o as_, �
J ` a� Q o d o t o a� � o'6v � >�°vs i � � �'� ��3:. �- � m
ti c�d � � ���m x ° °° � �ar c m °'o v o= ° ` u w° m o � G
p o c-o�' u � c �, �cy o� ° o °'oa'_ '" �; °, o `- �"' ° �o d,c U. m 3
x � o ..Q� a 3 o E o o �"D � u „ E N t� �,� m � m o- 6 O
{y a� o N c � �n � °'� s.X •"- _ � o � 3 fl-"" d � o Q c... o� dy �
0 E� c o �� N m � � �a � N'w � c"' ° m�° o % 3 O ., .'n o'u O 'cD
° ° " u d c� sv 3 � m o ov :�
� a m
p .,. . p' 6l N m h L
� t •- O O ,n � n � O O Ot p � �tt �'J O U �s C � d'¢ O �� ; � } '
C
u1 �°°,E C p s N O v o S O�`..� �,�—N 0'� G a � .— - .
Z � 'C 4.O d O t,^ O N � � .
w ; C p O V C tJ }`� � 01 y�j•0 �• ; •
O o n N � ,. o o_ � �,,, p a s_�
� N � � m O Ol N�� V'O
p� � N Q�j �V V1
Lv � �.p II'
�
�
r
2
a
�
� "
Z
t
\ p
2
s
O
� ti
�
Z
: . �/i