HomeMy WebLinkAbout1167A (7) WORKERS'COMPENSATION DECLARATION qppl.ICATlOR! FOR PERMIT �
I hereby affirm thol I have a certificate of consent to self
insure,or a cerlificate of Workers'Campensation Insuronce, ��3� HEATING - VENTIlATING - AIR CONDITIONING
or a certified copy thereof�Sec.3800,Lab.C.) �_818(REV.10/81� G��3�
��Y Na 1021516 Company State Fund
Carlified copy is hereby furnished. TR'� 44824 COUNTY OF lOS ANGELES JOB'� 1111 BUILDING AND SAPETY PH# 4
� Cert�lied copy is filed with the co�nty bullding inspec- FOR APPLICANT TO FILL IN BUIIDING
tion department. ADDRE55
7-23-$� (PRINTORTVPEONIV) t Rim Lane
Dafe Applicani NO. TVPE OF APPLIANCE OR EQUIPMENT PEE ��ALITY Diamond Bar
. CERTIFICATE OF EXEMPTION OM WORKERS' NEAREST
COMPENSATION IN URANCE CttOSS 57.
(Thic soc�lon nwd noT bo complofad if thp work involred by Ag�RPTION tIN1T,BTU DISiRICT NO. PROCESSED BY
tha porm{t��for ono hundrad dollari(SI00)or lect.) qIR HANDLING UNIT,CFM � ✓� ��
I teAify that in ihe performance of the work for which this
permit is issued,I shall not employ any person in any manner gp��ER,BiU
so as fo hecome subject to the Workers'COTPElISpflOfl LaW3, APPROVALS OATE INSPECIOR'$$iGNATURE
Date �pplicani 1 COMPRESSOR,BTU 48,OOO IO OO ROUGH �'�� �r
NOTICE TO APPLICANT: If, offer making this Certifitate of VEN71L471pN SYSTEM FINAL
Ezemption, you should become subject to the Workers'
Compenw�ion provisions o4 the Labor Code,you must forfh- EyqppRATIVE COOLER VALIDAFION �
with comply with such provisions or this permit sholl be
deemed revoked. FURNACE: FAU x Ggpy ITY
LIC�NSED CONTRACTORS OECLARATION 1 FtOOR BTU `��•�1�— 10 OO
I hereby affirm ihot 1 am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNI7_
'(commencing with Section 7000)of Division 3 of the Business ' WA��
and Rofessions Code,a�d my license is in full force and effect. Y�
468609 c-20 INLETS & OULETS ,� Q
license Num6ar Lic.Cla:s � V
Contractor =rvineW2st pa1e 7-23-87 O
O y
I am exempl under Sec.
Plan check fee �
B.BP.C.fot ihis reason� uf
Dale:
PERMIT 155llING FEE S 10 50 ?
Signa�ure TOTAL FEE Q(�
OWNER-BUILDER DECLARATION PLAN CHECK APPlIG4NT � �`� 1 �'7^.
I heie6y affirm thaf I am exemp�from�he Coniracior's License � � �
Law for the following reason (Secfion 703L5, Business and N,4ME . ��� � �`�
Professions Code): � : a -;c ^,
❑ I, as owner of the properiy, o� my empbyees wi�h �DRE55 " � '- `'
�wages as their sole compensation,w�ll do the wo�k and e ., „, - '�_ �
� the strudure is not inlended or offered for sale(Seclion CITY TEL NO. - �
7044,Business and Professions Code�. r.z_,�Z-�
� ❑ I,as owner of�he p�operty,am exdusively controcting OwNER �Villi3m Lyon Company � G�`�..„., .: i
with licensed contraciors to construct the project(Sec- DDRE55 19 Corporate Plaza
lion 7044,B�siness and Professions Code).
CONSTRUCTION�LENDING AGENCY arv Newport Beach 92660�i,N�,714) 833-360� � �..
I hereby affirm thot ihere is a consiruciion lending ogency for �
the performance of the work for which this permit is issued CONTRACfORIYV1712W23t Ht & AlZ'
(Sec.3097,Civ.C.).
nooaess 63B Southern Ave.
Lender's Name
Lender's Address
��TY Orange Ca 92665 rei.rio.(714} 921-080
I cartify that I hora read�his application and state that the ST�N��. 468609 �LA� C-20
above information is mrrect.I agree to mmply with all County •
ordinances and State laws reloting to building consiruction, . .
and hereby a�fhorize representatives of this County to enfer
upon the above-menrioned properry for inspection purposes. SEE REVERSE FOR EXPLANATORY IANGUAGE
" 7-23-87
ature of Applicant or Agent Dare
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