HomeMy WebLinkAbout1138A YWORKERS'COMPENSATIONOECIARATION APPLICATlOR! FOP. PERMIT �
I hereb affMm that I have a certifimte of consent to self
ins�re,or o certificate of Workers'Compensarion Insurance, ��� HEATING - VENTI�ATING - AIR CONDITIONING
or o certified topy thereof(Sec.380p,Lab.C.)
CE-818(REV.10/81)
P❑olicyNo. 1021516 Company State Fund �pf�{ �l.
'7
Certified copy is hareby turnished. TR# 44824 COUNTY OF LOS ANGELES JOB# 1111 BUILDING AND SAFETY PH# 4
� Certi�ed copy is filed with the county building inspec- FOR APPLICANT TO FILL IN auao�NG
tian deparlmenf. qDDRE55 20781 East Rim Lane
(PRINT OR TYPE ONIY)
Dare 7-23—$7 qpplitant IOCALITY Diamond Bar
, NO. TYPE OF APPLIANCE OR EQUIPMENT . FEE
CERTIFICATE OF EXEMPTION F M WORKERS' NEAaEST
COMPENSATION INSURANCE CRO55 S7. ..
(This sx4ion naad nol be complafod II tha work involvod b� ABSORPTION 11N1T,BTU oismi[r rvo. � Peo[ESSED er
fhr p�rmif is for ont hundrod dollars(;100)or lau.)
AIR HANDUNG UNIT,CFM � � ', r
�certify that in ihe performonce of the work for which this w
permit is iss�ed,I shall not employ any person in any manner gpILER,BTU
so as to become subject to the Workers'Compensotion�qWS. APPROVAlS onre INSPEClOR'S SIGNpiURE
Dafe opplicant 1 COMPRESSOR,BTU 4R�000 1� DO ROUGH ��e
NOTICE TO APPLICANT: If, af�er making Ihis Certifimte of VEN7ILATION SVS7EM FINAL
Exemptian, you should 6ecome subject +o ihe Worken'
Compenwtion provisions of the tabor Code,you must foAh- �qpqtqTiyE COOLER VALIDATtON
with comply with such provisions or rhis permit shall be
deemed revoked. � FURNACE. FAU X GRAVITY
LICENSED CONTRACTORS DECLARATION 1 FtOOR BTU 0(1,M(1 lO OO
I hereby affirm that I om ticensed under provisions of Chapier 9 HEATER: SUSPENDED UNIt_ .
�(commanci'g with Section 7000)of Divis'ron 3 of the 8usiness � WAIL '
and Profeuiona Code,ond my license is in fu�i force and effact. � �
a
License Num6er 468609 lic.Class c-2� ,_ � � �
V
IrvineWest 7-23-87 °L
Contrauor Date . Q
❑ 1 am exemp�under Sec. V
Plan check fee ` � � ���'' "'
B.&P.C.for this reason� � � o'
�; . . . . .n 'n
Dafe:
PERMIT ISSUING FEE; 10 50 z
Signature T�TAL PEE. � I - a S�i-`�;
OWNER-BUILDER DECLARATION Pll+N CHECK APPUCANT � � , 0 4 c,,`;G�;
1 he�eby affirm that I am exempt from the Contractols license � v
Law for the following reoson(Section 7031.5, Business and NAME � r•. n�_�;^
Professions Code): - u'�.`''•. � .
❑ I, os owner of the properly, or my employees�with ADDRE55
wagas as their sole compansarion,wili do�ha work and
. the srrucWre is no�intended or offered for sale(Sedion CITY TEL NO.
7044,Business and Professions Code).
❑ OWNER William Lyon Company .
I,as owner of ihe property,am exclusively contracting
with licensed mntracrors to construcf fhe projact(Ser D�RE55 19 Corporate PIdZd
. tion 7044,Business and Profeuions Code).
CONSTRUCfION LENDING AGENCY CtTr Newport��Beach 92660re�.Nd714) t333-360 � �
1 hereby affirm thot there is a construction lending agency for �
ihe performonce of ihe work for which this permit is issued CONTRACTOR
(Sec.3097,Civ.C.). . rvineL4est Ht & Air ._ , , .
ADDRE55 638 Southern Ave. - �
Lendar'a Name
orv Oran e Ca 92665 TE�.No.(714) 921—OS 0
lender's Address g
I certify that I hove read this application and stpte thm Ihe uCENSE NO. 468609 ���,q� C-20
above information is corred.I ogree to comply with oll County �
ordinances and Sto�e lows relating to building conshuction,
and hereby authorize representatives of rhis County to enter ' .
0 on the above-men ioned properry ior inspection p�rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
7-23-8
Si alure of Applicont w Agent Date '
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