HomeMy WebLinkAbout1140A WORKERS'COMPENSATION DECLARATION APPL{CATIOld FOR PERMIT ��
I hereby affirm tha� I bave o certificate of consen�ta self .
insure,or o certifica�e of Workers'Compensof�on InsU�once, ���� HEATING - VENTILATING - AIR CONDITIONING
or a cerfified copy thereof(Sec.3800,Lob.C.) .
CE-B16�REV.10/81� /�
a�y Na, 1021516 Compony State Fund � �Gt�'lp
Certified copy is hereby f�rnished. TR$ 44824 COUNTY OP LOS ANGELES JOS# 1111 BUILDING AND SAFETY pH$ 4
� Certi�(ed copy is filed with the co�nty building inspec- FOR APPLICANT TO FILL IN BUILDING
fion department. ADDRE55 20769 East Rim Lane
(PRINT OR TYPE ONLY)
Date 7—_ �—�Applimnt ' '� LOCALiTV
NO. TYPE OF APPLIANCE OR EOUIPMENT FEE
CERTIFICATE OF EXEMPTION OM WORKERS' NEa.RESi
COMPENSATION INSURANCE CRO5557.
(TAif wcfion n�d noT bo complofad if Tha work involrad by pBSORP710N UNIT,BTU OISTRICT NO. GROCESSED 6Y
tho parmil is for one hundrad doHarc(5100)or locs.) �
I certify that in the performance of the work for which this A�R HANDUNG UNIT,CFM �Lv1 ' - r
/ 0 I V\J
permit is issued,I ahall not employ any person in ony manner �
so as to�become subjett to the Workars'Compensotion�Ow3. ���ER,BTU pp7ROVALS DATE INSPECTOR'S SIGNA7URE
1 CpMPRE550R,BTU 48���� 10 �� ROUGH �+�
Dafe Anpli[ant . . . e� c7�-�Q
NOiICE TO APPLICANT� If, ofter making this Certificate of vEN71V,TioN SvSTEIu FINAL �
Exemption, yo� ahovld become s�bject to the Workers ..... . . .
Compenwtion provisions of the Labar Code,you must forth- EVAPORATIVE COOLER VALIDATION
with tomply with sucfi provisions or this permit sholl be � �
deemed revoked. � 1 FURNACE: FAU_G�IT`�_ l0 00
- IICENSED CONTRACTORS DECIARAiION � F�OOR aiu � �
I hereby affirm thof l om licensed under provisions of Chapter 9 �qTER: SUSPENDEO � � �� UNIT_ �� -
-(mmmencing with Section 7�00�af Division 3 of the Business - W/+«
and Professions Code,and my license is in full force and effed. �'
(� INLETS fi OULETS � °�
468609 c-20 O
license Number Lic Class � � � � U
irvineWeat 7-23-87 � ,. .. O
Contractor Date `� 1 �{ ���'
. ❑ 1 am ezempt onder Sec. R�o m s %; r
l)
Ptan check fee � ' `�' F�'� a
H
B.BP.C.for this reason' hERMIT ISSUING FEf S 10 50 • _ �. , ,;,- ?
Date:
Signo�ure __. ...._._......TOTAI.FEE L�� .(yv �;;�:-—?,f
_ .. QWNER-BUILDER DEGIARATIflN�� � � _ PIAN CHEC7[APPu[Ah➢[ � � � � - . �
I hereby affirm thot I om e:empt from the Coniroctor's License � � ����� ��� �
Law for the fol�owing reason(Section 7031.5,.Businea:and NAAAE - . �
Professions Code�: � � �� �
❑ I, os owner of the property, or my employee� with �RE55
wages as their sole compenwtion,will do tha work and -
� the structure is not iNended w offered for sole(Sedion CITY TEL NO. .
7044,Businass and Pwfessions Code). ,
❑ OYVNE(i William Lyon Company
1,as owner of ihe property,am exciusively cantracfing
with licensed coniractors to consiruct the project(Seo- ��� 19 Corporate PZdZa
tion 7044,6usineu and Professions Cade). � � � • ADORE55
C�NSTRUCTIONIEN�INGAGENCY -- -- ��T�-NewPOrt Beac� 92660T�i N6714) 833-360
� I hereby affirm that there is a construction lending agency for ,
the performonce of ihe work for which rhis permit is issued CONTRACTORIYV1I12WeSt HtCJ & Aii'
(Set.3097,Civ.C..). .
. ADDRE55 638 Southern Ave.
lender's Name
arv Orange Ca 92665 TEi.No(714) 921-08
Lender's Add�ess STATE 468609 ��c. c-20
1 tertify that I hove read this applicotian ond slote Ihat the tICENSE NO. ClASS
above information is correct.1 agree�o comply with all Counry
ordinances and Stare laws reloting ro 6uilding mnstruction, .
and hereby aulhorize representaiives of�his CouMy�o enter .
upan the a6ove-m ntioned properry for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
7-23-87
npture of Applicpnt or Ageni Oate �
N �rs � � �s N � ._� � � �soo �� � � � � � � �
'o�L � � o.� .3 y o o a� � a � y c �'�'o o v o � o
o a d c a
p 0 �'E �n� � p�a � � � 7 �e. � O y tl� �'t T� 0 p O j . . . _ .
w ° m c c ,t' °'r o� v 2 m . p u y U a ` .
Z �j o �� ai rnh ��v o N� 3 ar o� c-°a�-� ��= _c o o a .
O m � $ > � '" � E � o c � " r Q �' `m.c° �.c E � °i u L '- v ��.
F- �` p o 0 0 0 � � o w � � � _. o -�p x � n; � ° m . .
� E c � E�„_�-_ m° �,°—°o?� -°.°o o'o � `w o ao E c o 0 3 v
Q ° $ �; "' °� °' m' � ' � a m u o ° a°i o o � � " U o c '—"
V '� � � v = .� o � �r T E a �� c o E o a, c o ?,o p o o-.
W a 4 0 �E m r c d E � 4 p_c s ''� o- u � N � �� �
E .. a ^ � c a w < a v o '� >, u c�
W y 3 0� or�u° m c o � o o m as � m c� n °-o � a a o 3
U � a� �...M x o o �m ° � • �'-� u ` a` � = .°
� E° „ a3c °i o w-o 'ioHti °s� s � o c � c
� °Ooo ��� oo .� E� � s _`mc � >v � 3 ;� ° � � � °�„ '� °
�t � . " � '^ �-c d a o o c ° v o w,� o o�.o v � o c � a
o[ ._c°L a! � �.o °; co c �'��-m `w `o v�° E o m � ,t o c c ro� a'� u � ,�
Z E.° � E h ` 'N j°`d o a .. 3 N � o �� Q..� a 3 a 3 d � 3 � 3 h � +
� _ d � a.a•- o rn a'> � - � -� o.� o � � y— �J `o � ° a
�0 3 c o-o os`o m°' o " � o vm „ �, o "�'v o °Lm � a"i a £ °
� �,� � ° `-.c o o�o°� os`— � � va E� �-�ov 3v v� c � .
�' °' c •`� m a »- o a N� �n ° �❑ ��^ -+'O�c c Q �'-�o ❑ �o u� a l� � a � �
� L u � d� � d o w � `oo o° i;n o'� ° c E 3 0 0 ,;; -or�r o °� a 3
_ � m o trEucn � � a 3 3 . . o c _ 3 _ m � O
N
W
� � �
N I
� I
d
N
Z �
' I
I
I
W
� F�
, _ 0
Z
. N
,• , �
, .. C
W
. d.
N
z
