HomeMy WebLinkAbout1136A (9) WORKERS'COMPENSATION DECLARATION � APPL�CATION FOR PERMIT �
I heraby affirm that I have a certifimfe of mnsent fo self
insure,or a certificate of Workers'Compensat�on Insurance, i��� HEATING - VENTILATING - AIR CONDITIONING
or a cehified copy thereof(Sec.3800,Lob.C.)
CF-B1B.(REV.iB/81)
P❑oliq No.�CompanY StBte F"nd LOf��
Certified copy is hereby furnished. TR# 44824 COUNTY OF LOS ANGELES JOB# 1111 BUILDING AND SAFETY PH$ 4
� CertlfQed copy is filad with tha mun�y building��sPec- . FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS 20793 East Rim Lnae
(PRINT OR TYPE ONLY)
Da�e�Applicon� �oCaurr Diamond Bar
NO. TYPE OF APPIIANCE OR EDUIPMENT FEE
CERTIFICATE OF EXEM7TION� OM WORKERS' NEAREST
COMPENSAiION INSURANCE CRO55 ST.
(Thls�oction n�d not ba complalod if 1ho werk inrolvad by ABSORPTION UNIT,BTU OISTPICT NO PfiOCESSED BY
1ho parmit is for on�i�undnd dollon(5100)or las�.) �
AIR NANCIING UNIT,CFM ✓�y� �
I certity ihat in fhe perFormance af ihe work for which ihis / i�
permit is issued,I shall nat employ any person in any manner gp��ER,B7U
so as to become su6jetl to the Warkers'Compensntian Lows. nvveovnis DAiE INSPKTOR'S SIGNATURE
Dale Appiicant 1 � COMPRESSOR,BTU 4S•OOO IO OO ROUGH
NOTICE TO APPLICANT: If, after making this Certifiwte of VENTnA7iOtd Sv57EM FINAL
Eaempfion, you should become subject ro the Workers' ,
Campansniion provisians of fhe Lohor Code,you musi forth- EVAPORATWE COOIER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. 1 FLOOR� FAU eru Gy��.�1�— 10 00 '
LICENSED CONFRACTOR$DECLARATION
I hereby offirm thaT I am(icensed under provisions of Chapler 9 HEATER� SUSPENDED - UNIT_
�(commancing with Section 7000)of Division 3 of ihe 9usiness '� WA«
and Professions Code,and my license is in{ull.force ond eHed. y
INLyTS & OULETS
�
License Number 468609 �ic.Class c-20 � U
IrvineWest 7-23-87 ,-->> � 3<,p. Q
Coniractor Date
O �¢• s • • a�. u�"
1 am ezempl under Sec. W
Plon check fee � a a �.�,,,� N
� 8.8P.C.for Ihis reason- .
PERMIT ISSUING FEE S 10 50 Z
- Date: • . o -:' '.,'��T
�
Signatore TOFAL FEE S" �]p � `
; �OWNER-BUIL�ER DECLARATION PLAN CHECK APPIICAN7
1 hereby affirm tha�I am exempi from the Cantracror's License . � u~C�`
Law for the following reason(Section 7037.5,Business and NAME
Professions Code):
❑ I, os owner of�he property, or my employees wilh ADDRE55 .
wages as their sole compensotron,wi41 do tbe work and
ihe strocture is not intended or affered for sale(Settion CITV . TEL NO.
7044,8usiness ond Professions Code). OWNER Lvilliam Lyon Company
❑ I,as owner of the properly,am exclusively contracting
with licensed coMradors fo consiruct 1he projed(Ser DDRESS 19 Corporate Plaza
tion 7044,Business and Professians Code}.
CONSTRUCTION LENDING AGENCY cirr Newport Beach 92660TE�-N�7i4) 833-3600 �
I hereby affirm thot there is a construction�ending agency for �
fhe performance of ihe work for which this permit is issued CONTRACTORIrV1I10W2SC. Ht. & Alx'
(Sec.3097,Civ.C.). .
^o�Eu 638 Southern Ave.
tender's Name .
Lender's Address ��Tr OrdAcj2 Cd 92665 ie�.No.(714) 921-080
1 cer�ify ihai I have read this app(imtion and state ihal the ilcErise No. 468609 cwss e-20
above intormation is corrett.I agree to comply with all County
ordinances and S�ate laws�elating lo building construction, �
and hereby authorize representafives of Ihis Counly to enter � �
upon�he ahove-mentioned proparty for inspection purposes. - SEE REVERSE FOR EXPLANATQRY LANGUAGE
7-23-87 '
afure of ApplimN or Ageni- Dale
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