HomeMy WebLinkAbout1137A WORKERS'COMPENSATION�ECIARATION App��CATION FOR PERMIT �
i here6y affirm �ho� I have a certificare of consent�o self
ins�re,or a certificate of Workers'Compensation Inturance, ��� HEATING - VENTItATING - AIR CONDITIONING
w a cenified copy�hereof(Sec.3800,Lob.C.) CE-818(REV.10/81)
P❑olicy No. 1021SI.G Compony State Fund
Certified copy is hereby furnished. TR� 44824 COUNTY OF LOS ANGELES JOB# 11I1 BUIL�ING AND SAFETY pH$ 4
� Certi�`ied copy is filed with the county building insper- FOR APPLICANT TO FILL IN 6UIlDING z��g'] Eas t Rim Ld1te
tion deportment. ADDRESS
(PRINT OR TYPE ONLY)
Dote 7-7�—R7 App���ani �f Np TYPE OF APPIIANCE OR EOl11PMENT FEE �OCALITY Diamond Bar
CERTIFICATE OF EXEMPTIO -ROM WQRKERS' NEAREST
COMPENSATION INSURANCE CRO55 ST.
ABSORPTION UNIT,BTU DISTRICT NO. PRO[ESSED BY
(Thli taefion n�ad no�bo complNad IF fha work Involred by
Yha parmif is for ona hundrad dollara(SIYO)or Ipt.) qIR HANDLWG IINIT,CFM � �/'�.y� �
I certify fha�in the performance of the work for which this � � �
permit ts issued,I shall not employ any person in any manner
so as�o become subject�o the Workers'Compensation Laws. BOiIER,aTu APPROVALS DATE WSPEQOR'SSIGNAiUFE
Date opplicont 1 COMPRESSOR,BTU 4$�OOO 10 �� ROUGH �
NOTICE TO APPLICANT: tf, after moking this Certifica�e of VENTIL4TION SYSTEM FiNAI
Exemption, you ahould become su6ject to the Workers'
COmpensation provisions of the Labor Code,you musl forth- EVAPORATNE COOLER VALIDATION
with tomp�y with such provisions or ihis pe�mit shall be
deemed�evoked. 1 FURNACE: FAU_Gfi�P](I`�_ lo 00
LICENSED CONTRACTORS DECLARATION FLOOR BtU ti� �
I hereby affirm ihoF!am licensed under provisions of Chapfer 9 SUSPENOED UNI7_
�(commenCing with Section 7000)of Division 3 af the Business ' HEATER: WA��
and Profeuions Code,and my license is in fuli force and effect. >
A68609 c-20 � INLETS 6 OULETS v 0.
licensa Number Lic C7ass ► U
IrvineWest 7-23-87 �
Gontractor Du�e ��—
❑ I om exempt�nder Sec. ` � } 7 ! C W
Plcn check fee :+� � F r y �
9.8P.C.to.this reason pERMlT ISSUING FEE S 10 50 � ° '�+�%'�_ Z
Date: • _. : r, •� ..:� ..
S�qnatu.e TOTAL FEE �t V z._n �
OWNER•BUIIDER DECLARATION PLAN CHECK APPIICANT � �
I hereby affirm thol I am eaempf From the Confrodor's License �
Law for the following reason(Section 7031.5, Business and NAME
Pro4essions Code�: .
❑ I, as owner of ihe property, or my employees with A��RESS
wages as their sole compensaiion,will do ihe work and �
the strudure is not intended or offered for wle(Section CITY TEL.NO.
7044,Business and Professions Code). OWNER William Lyon Company
❑ I,os owner of the property,am exdusively contracting
with licensed contracfors to conslrucl the project(Sec- DDRE55 19 Corporate Plaza
tion 7044,B�siness ond Professions Code).
CONSTRUCTION LENDING AGENCY �iT� Newport Beach 92660�1.Nd.714) 833-360 .
I heraby affirm tha�there is a constroction lending agency for ► �
the performonce of the work fo.which this permir is issued �ONTRACTORj=V1Il8W2St Htg 6 Air
(Sec.3097,Civ.C.). - . . . .
ADDRE55 638 Southern Ave. � �
lender's Name
nrr Orange Ca 92665 re�.rv.o.(714) 921-08
Lender's Address
I certif that 1 have reod this a liwlion and state ihat the STATE 468609 ���� C-20
y pp LICENSE NO. ClAS$
o6ove informa�ion is corred.I agree�o comply with all County
ordinances and State laws relating to building tonstr�cfion,
and hereby authorize represematives of lhis Counry to enter
u n the��e ��p�operry for inspection porposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
7-23-87
5 ature of Applimnl or Agent Dote
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