HomeMy WebLinkAbout1689A �WORKERS'COM7ENSATION DECLARATION APPLICATION FOR PERAAI� �
I here6y aff'rtm thot I have a certificate of consent to self
tnsure,or a cenificaie of Workers'Compensation Insurance, ���� HEATING - VENTfLATING - AIR CONDITIONING
or a certified copy thereof(Sec.3800,Lab.C.) CE-818(REV.10/61)
Q�y No.PWC 05067��m�ny Golden Eagle Ins.
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed with the county building��SPec- FOR APPLICANT TO FILL IN BUILDING
tion department. (pRINT OR TYPE ONtY) AD�RESS v1eW LBIIe
Date 5-2¢'89 ApplimniRa.IICt.lO Air, IIIC. NO. TVPE OF A7PUANCE OR EQUIPMENT FEE ����TY
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST �� 23 Job� 876
COMPENSATION INSURANCE CROSS S7.
(Thls wclbn na�d not 6a wmplafed H Ih�work inrolr�d by ABSOR�T�ON UNIT,BTU �ISTRICT NO. VKOCESSED BY
fha pormk is for ona hundr�d dollar�(i100)or loss.} � /�
AIR HAN�LING UNIi,CFM
I certify that in the performance of the work for which this v � Q^�
pe�mit is issued,I shall not employ any person in any manner
so as to 6ecome sobject to the Workers'Compensation Laws. sOi�eR,eTU pppQpVALS DATF INSFECiOR'S SIGNATURE
Date npP���a�� 2 COMPRESSOR,BTU 30���� 20 �� ROUGH ��
� �ICE TO APPLICANT: If, after mnking this Cerlificate of VENTILATION SYSTEM FINAL Z-Z�_4
.nption, you should become subject to the Workers'
Compensotion provisions of the Labor Code,you must forth- EVAPORATIVE COOLER VALIDATIDN
with tompiy with such provisions br this permit shall 6e
deamed revoked. 2 FURNACE: FA��G1tN(ibv�_ 20 00
LICENSED CONTRACTORS DECLARATION FLOOR BTUOD U ,
i here6y offirm lhar I am licensed under provisions of Chapter 9 HEAteR: SUSPENDFD UwT_
��commencing with Sectian 7000)of Diwsion 3 of the Business - '�'Au
and Professions Code,and my license is in full forte and effect. Y
15 Re isters @ 1.75 Ea 26 25 �'7 b c 9 r: �
License Number Lic.Class , �� � � � �� V
OC
Conirac�Or Dafe � o �7�7 r� O
❑ 1 am ezempt under Sec. _ _ V
Plan check fee • _ � i r.'+- °7
B.&P.C.for this reason ` v�i
PERMlT ISSUtNG FEE S 10 0 �4 c O—t:o x
Date:
Signature
TOTALFEF 76 75
OWNER-BUILDER DECtARATION PLAN CHECK APttICANT
1 hereby affirm thot I am exempt from Ihe Contracior's License �
Law for the following reason(Section 7037.5, 8usiness and nlMnE
{P•�fessions Code):
` I, as owner of ihe property, or my employees with ADDRE55
� wages as iheir sole compensation,will do the work and CITY rEL nlo.
the strucwre is na1 intended or offered for sale(Section
70d4,Business and Professions Code).
OWNER r�e �deII GT011
❑ I,as owner of the property,am exdusively contrading
with licensed coniraUors b cons�rud the project(Seo- �"u"�� 1074 Parkviev Drive �201
tion 7044,Business and Profess�ons Code). a.oDRE55
CONSTRUCTION IENDiNG AGENCY �iTr �pyi�� rE�.No.glg-9(,7-95�+1
I here6y affirm thal tbere is a construdion lending agency for �
the performonce of the work for which rhis permit is issued CONTRACTOR �NCH� �R i�C.
(Sac.3097,Civ.C.).
ADDRESS 1232 W. 9th Street
Lender's Nome
aTr Upland TE�.No714-g81-k801
lender's Address
S7ATE 1� LIC.
I cerrify rhat I have reod rhis opplicotion ond stare rhai the LICENSE NO. 38O �+3 ClnSS C-20
obove informaiion is correct.I ogree to comply wifh all Counry
ordinances and 51ote laws relating io building consrruction,
and hereby authorize representatives of this County to enter
upon th ba -mention property for inspection p�rposes. SEE RE4ERSE FOR EXPLANATORY LANGUAGE
�� �a - 8'_
Signoture of Applicant or Agent Dale �
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