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WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT �
i hereby affirm that I ha�e a certificate of consent to self
��S��e,or a certifiwte of Wwkers'Compensation i�s��a��a, ,bA� HEATING - VENTILATING - AIR CONDITIONING
o�a certified copy�hereof(Sec.3800,Lab.C.� � �E-Bi8(REv.io/8�) �
vo��cy Na. wC�a��7 North Brook c�
❑ Certified copy is hereby f�rnished. Job#1469 COUNTY OF LOS ANGELES Lt#p�Pl#o�- BUILDING ANDSAFETY Tr#43760
� Certified copy is filed with�he county building inspec- FOR APPLfCANT TO FILL IN 6UlLDING
tion department. J (PRINT OR TYPE pNIY) �4DDRE55 p� East Rim
pa�e na_�^t_Af2 qPP���a�� LOCALITY Diamond Bar
NO. TVPE Of APPIIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEARESi
COMPENSATION INSURANCE ceoss 57.
(Thls sxllon naod not be compleled if 1ho work involv.d by
ABSORMION UNIT,BTLI ' oISTRiC7 NO. rRDCE55
the permff b for oiw hundrod dol{ara(5100)or loss.) �
AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this
permit is issued,1 aholl not employ any person in ony manner
so as to bewme subjecf lo ihe Workers'Compen5otion Laws. BOILER,8TU qppppyp�5 �ATE INSPECTOR'S SIGNATURE
�
Dale- epplicont 1 COMPRESSOR,BTU 6�,��� 1� �� ROUGH �
NOTICE TO APPIICANT: If, qfier moking lhis Certificate of VENTu.4TioN SYSTEM FINAL '� ���
Exemplion, you shoufd become s�bject ta fhe Workers'
Compensotian provisions of the tobor Code,you must forth- EVAP�ORATIVE GOOLER YALIDATION
with comply with such provisions or this permit shal� be
. daemed revoked. - FURNACE: FAU_y,GRAVITY
. UCENSE�fONTRACTORS DECLARATION � FLOOz etu
I hereby affirm that I am licensed nnder provisions of Chapter 9 SUSPENDED UNR_
HEATER: WALL
�(commencing with Section 700Q)of Division 3.of the 9usiness
ond Professians Code,and my license is in full force and effed. �
468609 C-20 V
License Number �ic.Class -
Inlets & outlets � � �
Confroclor �otg �/�' t1R—ll—$ �
� v
I am exempt under Sec. W
Plan check fee a
B.dP.C.for fhis reason Z
Date: PERMIT ISSUING FEE'j 10 50 : 1 ^^%i'.
TOTAL FEE s: • • • o :K
- Signature "
OWNER-BUILDER DECLARATION PLAN CJiECK APPLICANT � .; i�., �: �r
1 hereby offirm tha�I am exempl from the Con}roctor's License � � .
law tor the followi�g reason(SeUion 7037.5, Business and NAME e - . i -
Professions Code): .
❑ I, as owner of the property, or my employees with ADDRE55 �i .�: � �i—^.r^.
wages as their sole mmpensaiion,will do ihe work ond
fhe structure i:not intended or offered for sale(Secrion �ITY TEI.NO.
7044,Business and Professions Code).
� � OkVNER The William Lyon Co.
❑ I,as owner of�he property,am exclusively contracling
with licensed contracrors ro consiruU the project(Seo ��� .
tion 7044,Business and Profassions Code). � ADDRE55 19 Cortorate Pl
CONSTRUCTION LENDING AGENCY CITY Newport Beach rei.r�7.4-833-3600
I hereby affirm tha�there is a construction lending agency ior ' �
the performance of the work fw which this permit is issued� �ONTRAC70R IrvineWest HtCj fi A�C,' .
(Sec.3097,Civ.C.).
aooaess 638 Southern Ave
Lender's Name �
aTv Orange rE� No.921-0800
Lender's Address
, I certify thaf�have read this application and state ihat the. IICENSE NO. 46H6O9 C�a.SS C-20� �
above informolion is correct.1 ogree to comply with all Coun�y
ordinonces and State laws relating ro 6uilding construdion, - '
and hereby authorize representaiives of this County to enter .
on e ov -m ioned property for fnspection purposes. SEE REYERSE FOR EXPLANATORY LANGUAGE
08-11-88
Signotura oF Applicanl or Agem Date � � �
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