HomeMy WebLinkAbout1139A (7) WORKERS'COMPENSATION DECLARATION APpLICAT101�! FOP PERMIT �
I hereby affirm that I have a certificate of consent to self \
insu�e,or a certifimte of Workers'Compensation Insurance, ���� HEATING - VENTilATING - AIR CONDITIONING
or p certified mpy thereof($ec.3800,Lab.C.)
CE-818(REV.10�81� �
P�ol�icyNo. 1n'7_�^�lti Company St'lt2 Func1 � La7�/�
Certified copy is hereby furnished. TR# 44824 COUNTY OF LOS ANGELES JOB# 1111 BUILDING AND SAFETY pH$ 4
� Cert�ed copy is filed with the county building inspec- FOR APPLICANT TO FILL IN sUitDiNG
tiondeparlmenf. (PRINTORTVPEONLY) ADDRE55 20775 East Rim Lane
pare � �3 g� qppiiconl iocauTr Diamond Bar
NO. TVPE OF APPLIANCE OR EqUIPMENT FEE
CERTIFICATE OF EXEMPTION M WORKERS' NEAREST
COMPENSATION INSURANCE CR05557.
(This-wct{on nvad not ba wmplalad iF the work inrolved bY ABSORP71oN UNIT.BTU DISTRICi NO. PpOCE55ED BY
}he permif i�for o�re hundrod dollun(5100)or leas.) q�R HANDIING UNIT,CFM
I certify that in the performance of the work for which ihis � `�^y} ��
permif is issued,I 5holl nol emplay any person in any mpnner gp��ER,BTU
so os to become subjeU to the Workers'Compensafion Laws. nrrcova.is DAiE MSiEC70R'S GNATURE
Dote app�i�p�� - 1 COMPRESSOR,6TU 4$,OOD I.O O� ROUGH 'j�? '�,�.$C �—
NOTICE TO APPIICANT: If, aNer making thit Cerrifimte of VENrIlA710N SYSTEM PINAL �
Exemption, you should bacome cubject to ihe Workers'
Compensation provisions of the Labor Code,you must forth- ¢yqppppnve COOteR � VALIDATION
with comply wi�h such provisions or this�permil shall 6e
deemed revoked. FURNACE: FAU_GRAYI''L_ lo 00
LICENSED CONTRACTORS DECLARATION � 1 FiooR Biu yV VUU �
� I hereby affirm that I am licensed under provisions of Chapte�9 SUSPENDE� UNIT_
HEASER: WA��
�(commencing with Secfion 7000)of Division 3 of the Business �
ond Professions Code,and my license is in full force and effed. >
INLETS 5 OULETS rf �
Licensa Number 468609 Lic.Cless C-20 � V
Irvine6Yest 7-23-87 �j � j C;1 �
Contractor Date O
❑ I am exempf under Sec � a • • o a�{ 1—
Plan check fee �
B.BP.C.for ihis reason- M
Date:
PERMIT ISSUING FEE S 10 50 '1 = �L� n��n z
Signature TOTAL FEE g QJ • . _ —
� OWNER-BUIL�ER DECLARATION PLAN CHECK APPI�CANT � � _
i here6y affirm ihat I am eaempl 4rom Ihe Cortfroctor's License ► ��'�'"—�� �
Law for the folfowing reason(Secfion 7031.5, Business and NAME
Professions Code): - � .
❑ I, as owner of the property, or my employees with ADDRE55
wages as iheir sole compensation,will do the work and �
the strvcture is not inlended or oHered for sale(Sedion CI7Y TEl NO.
7044,Business and Professions Code�.
OWNER William Lyon Company
❑ I,as owner of�he property,am exclusively controcting � .
with licensed coNroctors to ronsirud ihe projed(Seo ���' 19 �orporate Plaza
tion 7044,B�siness and Professions Code). ADORE55
CONSTRUCTION LENDING AGENCY aTv Newport Seach 92660�i.Nd.714) �833-360
� I here6y affirm thot there is a consiruciion lending agency for S
ihe performance of ihe work for which this permit is issued �ONTRACfORIY'V1R2WeSt HtGJ & A7.I
(Sec.3097,Civ.C.). �
ADDRESS 638 Southera Ave. � �
Lender's Name
arr Orange Ca 92665 r�.r�o.(714) 921—Q8
Lender's Address
I cerfify tha�I have reod this application and srote that ihe iicenis�No. 468609 ��� C-2� -
above in4ormation is correct.I agree to comply with all County . �
ordinonces and Srote laws relating to building mnsiruction, � - .
and hereby a�thorize representa�ives of this Coun�y to enter
on ihe above-ment ned property for�nspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
7-23-87
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