HomeMy WebLinkAbout1166A (7) WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT �
I hereby affirm that I have a certificale of consent to self
insure,or a ce�rficote of Workers'Compensation i�5�.a��e, HEATING - VENTItATING - AIR CONDITIONING
or o certifled copy ihereof(Sec.3800,La6.C.) 76A364C .
POollcy No.��Company
te Fund �'818�REV.10/81) ���
Cerlified copy is hereby furnished. TR� 44824 COUNTY OF LO$ANGELES JOS# 1111 BUILDING AND SAFETY PH$ 4
� Cer�i�ied copy is filed w�th the county 6uilding inspec- F�R APPLICANT TO FILL IN BU�LD�NG
tion depariment. (pRINT OR TYPE ONIV) ADDRESS East Rim Lane
oa4a �-23—a7 Appucan� 1O�`��TY Diamond Bar
NO. TYPE OF APPLIANCE ON EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FR WORKERS' NEnREST
COMPENSATION INSURANCE CRO55 ST.
A850RPTION 11NIT,BTU DISTRiCT NO. PROCESSED BY
(This sxfion naod not ba compleNd if 1ha wurk involvad b� �
fho pormft Is fur una hundrQd dollors(SI00)or losc.) . v"}ti, , r
AIR HAN�IING UNIT,CFM �. i
� I cartify that in the performance of the wwk for which this ��'V�"'
permit is iss�ed,�I shalf not employ any person in any manner gpi�ER,Biu
so as to become wbjecl to the Workers'Compensarion Laws. nvraovnts onTE INSPECiOR'SSIGNAiURE
Date - Applicpnf Z COMPRESSOR,BTU nR,.Onn 1� 00 ROUGH $���
NOTICE TO APPUCANT: If, af�er making this Certificate�of vENTIlA7lON SYSTEnn FiNnt
Exempfion, you sbould become subject to �he Workers'
Compansatian provisions of Ihe Labor Code,you must for�h- EVAPORATIVE COOLER VA��DA7�ON
with comply with such provisions or this permit shall be __._
deemed�e�oked. FURNACE: FAU X GRAVITY
LICENSED CONTRACTORS OECIARATION S FIOOR BTU lO 00 ,
I hereby affirm thot I am licensed under prorisions of Chapter 4 HEATER: SUSPENDED UNIT_
-(commencing with Section 7000)of Division 3 of iha Busineu ' WA��
and Rofessions Cade,and my I�cense is in full force ond effeci. � q},
0
License Num6er 468609 Lic.Gass G'20 � � U
IrvineWest 7-23—a7 �
Comracror Dare �:1 1 ,�F A �
❑ I am ezempt under Se�. Plan check fee � �° ` ° • d
B.&P.C.for Ihis reoson� �
PERMIT ISSUING FEE S 10 50 �
oore:
S�gnature T07A1 FEE $ � � ` `�1`�i i
OWNER-BUILDER DEQARATION PLAN CHECK APvIICAM • " ° . . _ ,
1 hereb�affirm ihat I am exempt from the Contractor's License � � ` �
law for the following reason(Sec�ion 7031.5, Business and NAME L'�i(',J—Q%
Professions Code): .
❑ I, as owner of the property, or my employees with /+DDRE55
wages as the�r sola compensation,will do ihe work and ��n, - FEL NO.
the strudure is not iNended or offered for sale�Setlian
7044,Business and ProFessions Code). OWNER -
❑ I,as owner of the property,om eaclusively contracting Willl.dm L}�ori Company
with licensed contractors to construct the project(Seo- '�'��
tion 7044,Business and Professions Code). ADDRE55 19 COrpOldte PldZd
CONSTRUCTION LEN�ING AGENCY cirv Newport Beach 92660rei.N�.714) 333-3600
I he�eby affirm that ihere is a mnstruction lending agency for ,
the performance of the work 4or which this permil is issued CONTRACTORT
(Sec.3047,Gv.C.). in West H� 8 Air
ADDRE55 638 Southern Ave.
Lender's Name
Lender's Address ��TY Orange Ca 926f,5 T���NO�(714) 921-080
I certify Ihat I have read lhis applicalion and state Ihal the iiceris�No. 468609 ��� C-2�
above information is correct.I ogree to comply with all County �
ordinances and Srate lows relating to building consiruction,
and hereby authorize representatives ot rhis County to enter
pon the above-mpntioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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