HomeMy WebLinkAbout1135A (9) WORKERS'COMPENSAiION DEClARA710N qpp�,ICATIOM FOR PERMIT � �
I hereby affirm that I have a tertificote of consent to self
insure,o.a cerfificate oF Workers'Compensarion Insurance, �6A3oa� HEATING - VENTILATING - AIR CONOITIONING
or a certif�ed copy thereof(Sec.3800,Lab.C.)
CF-B18(REV.10l81) /_
P❑ol�icy No. l(12l S1 F Company Sta+a Fnnrl �-(17��/ ,
Cerrified copy�s hereby furnished. TR4r` 44324 COUNTY OF LOS ANGELES JOB'� 1111 BUILDING AND SAFETY¢H# 4
� Cert�ied copy is filed with the counry building inspec- FOR APPLICANT TO FILL IN BWLDING
iion deparimenL (PRINT OR TVPE ONLY) ADDRE55
(M�e�Applicant � LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT fEE
CERTIFICATE OF EXEMpT10 ROM WORKERS' NEARE57
� COMPENSAifON 1 SURAh10E CRo55 57.
(7his swiion nood not bs complotwl IF tha work involrad b� ABSORPTION UNI7.BTU DISiRIQ NO. V40CESSEO BY
fh�pormll ta for ono hundnd doilars(i100)or(oa.) � �rn'� �
I tertify fhat in the performance of the wwk for which lhis AIR HANDLING UNIT,CFM
permit is iuued,I shail not emptay any person in any monner
so as ta become subject to the Workers'Compensp�ion.Lows. 90ILER,B7U qrpqovqts
DATE INSFECiOR'S SIGNATURE
Dote Applican� � COMPRESSOR,B711 ROUGH �
NOTICE TO APPLICANT: If, after making this Ce•tificote of VENTItATION SYSTEM FINAL
Exemption, yo� shoold become su6jed fo the Workers'
Compensation provisions of the La6or Code,yoo must For�h- EVAPOR.4TNE COOLER VALIDATION
with compiy with s�ch provisiana or this permit sholl be
deemed rCvnked. FURNACf: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR ��
I hereby oHirm Ihat I am licensed undar provisions o!Ghapler 9 SUSFErvDED UNIT_
�(commencing with Section 7000)of Division 3 of the Business HEA7ER: wA��
and Professiona Code,and my license�s in full face and effect.
ETS & OULETS I�I JII O
License Number 468609 ��c.Class C-20 � „f i V `�t V
Conlrotlor IrvineVdest �e 7-23-87
�' c e s • e� OC
❑ 1 am exempt under Sec, � ' ` 1%'i� ~j
Picn check fee W
B.BG.C.for this reason
o.
w
oora:
PERMIT ISSUING FEE S 10 50 � , , �.; �T Z
Signarure TOTAL FEE Qu �a�Z_c•�
OWNER-BUILDFR DECIARATION PLAN CHECK APPLICANT
I hareby affirm ihat f am exempt 4ram�he Con�rocior's License �
Law for Ihe following reason(Section 703L5, Business and NAME
Professions Code):
❑ 1, os owner of the property, or my�employees with �RE55 -
. wages os their sole compensaiion,will do ihe work and �ITY
the structure is not intended o�offered tor wle(Sedion TEt.NO.
70E4,Business and Professions Code).
OWNER y�illiam Lyon Company
❑ I,os owner of the praperty,am exclusively con�rocting
wilh iicensed conlroctors to construct the projetl(Sec- ODRESS 19 COIpO*d'tC Plaza �
�ion 7044,Business and Professians Code).
CONSTRUCTION IENDING AGENCY aTY Net9pOrt BedCh 92660rE�.N6714) 833-3600
I hereby affirm that there is a construction lending agency for �
the pe�formance ot the work for whith Ihis permit is issaed coNTencrorr�=vine4�est Ht
(sec.309�,G�.C.�. g & Air
A�DRESS 638 Southern Ave.
Lender's Name
��TY Orange Ca 92655 TEI.NO(7]_Q� 921-080
Lender's Address .
STATE LIC.
1 cer�ify thal 1 hove read this applica�ion und stale that ihe i��EN��, 468609 ��A� C-2�
above information is correct.I agree to comply with all Co�n�y
ordinonces ond Slote lows relating to building ronstruction,
and hereby outhorize representatives of this County to enter "
u on the abo�e-men ioned p�oper�y for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
7-23-87
nature of Applicm�or Agent Doie � �
� O
. > O `
� G pl � N v� D .
C L"O � 0 C O O N
.rT-� C G1 U T G � p,*- �-
i+ � L V �
N c •_m D � c N p-a ° a N s s o u .9
�y '^ �'^ � t`o."6 t ° fl.o � �m+� � ��- � p d
�
� ro �` o °n d ° � o y v t� E°,' m ;c ' � 3 3 n
r .ri y� o '' o+�n d s 3 ,_� o d s o •y„ �' �n o o �
o in O C�O. L ,'�,. d r .0 £ a� � L U C c�
0 M L 0 '^'O `n � 'O O > �Q � 3 d - 4,O O � ,n � D
T C 'V 'O v� ._ t N ; V � p � ' U C �
D� �� ��N � p n C� �C �Q O p C Q� O p �n � Q O C � ' G
cc � �•N� � ;� E 'an �.-ou o ° E3 Y� o. a. � �a°mu3 � o
V O � �; ..� a o u:
Y p � ��'O � �0 •�ns '�i � C O c r.'� 6' p, D p D 6 L J � 6
� .f. N� C m� v`". j N j � � T.,�- O 7.d N= p.O 61 C� C- O v�O v, y O
T' E � O-=P CII N T� � y � N P"6 6: C d "' S O'V � d � � 'O `!�
s�i, O p�T . � ... � y s L Q�.O p �� D'Y y Ur'` N .,Q- O'O y� O � L .:+ 7 t_
� o c d o�E c 4- c'" ° c Q� a o d 3 o m d �n-o °-= � a p
� "� m 4 0 0" E c -o c >-n ° > y '^ d E 3, � .,- • `p�
`� E c� �� ° °' `V c-. d.°° ° s mcv � Qv -o Oc ° z� J r ° o � � d t
V ., U d 3
"� ocv�' � � c ,n °'c = oc �vEo �,� 3 � °� md �+ m � d o- o O
� % ' O .. a"> 9.3 p E O" N :. �. ✓� t N.p.
u 3 v � �v � N m d � c m o m 3 a.�- m o Q C o c e�b C]
�y �o � o ?o °n �>"� �-�y � N?°o� ° m�° ° � 3 0 `°'-' .�n °`V o 6�
ao o � a,C]o ,9 0 ,. •. p m m w � o E �-o Q v�r N o,� y �
� � c b
p f �O ''' ���� `�'�L �c u o 0 7'Q N'7 s v o N� �V N.o; N s
� y N �. N � 4. at p v��� U ,p � t O J�..-
O � P„ O p 4�,,.J y m p. OC
y ��v n.o °L o�o �-O ° "L � ��, t ° �E °
2 "` o q ° `TL o o Nt�.c o sv, o � 3 . -
O ° �O
T Q �� ��G G�O O� �
S� N C 7 .;7 N�N N.�-
L " � G
S ," w � � �
J
� �
,
\
r \ �
Z
�
O
�Jr►
Z
` O
2
�
O
� �'o-
Z
� . `