HomeMy WebLinkAbout1688A (225) • WORKERS'COMPENSATION DECLARATION qpp��CAT10N FOR PERNiIT �
I heraby affirm that 1 have a certificate of consent to self
insure,or a cer�ificate of Workers'Compensation Insurance, HEATING - VENTI�ATING - AIR CONDITIONING
or o certified copy thereof(Sec.3800,Lab.C.) ��`��
CE-818(REV.10/81)
P❑al�icyNo.PWr n50Fil^'lmpany �:nlflan F�oIP T.�g, �
Certified copy is hereby fu�n�shed. COUNTY Of LOS ANGELES BUIIDING AND SAFETY
%❑ Certified topy is filed wirh the county building inspec- FOR APPLIG4NT TO Flll IN BUIL�ING
tion deparlmanl. (pRINT OR TYPE QNLY) ADDRE55
Date.,,—'�4— S� Applicant iocnuTv Diamond BaY 7'Tact;� k2582
NO. TYPE OF APPIIANCE OR EQLIIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEARE5T �r� 22 Job� 876
CAMPENSATION INSURANCE CRO55 ST.
(Thl�wcTion nood nof be rompleted if the work involvad by AB�PTION UNIT,BTU p15TRICT NO. PRp�F55ED BY
1hv p�rmN I�for on�h�ndrod doilws(5100}or les�.} .(y�
AIR HAN�LING UNIT,CFM U \�\0. O��
1 certify that in the perfo�mance of the work for which this
permit is issued,I shall not employ ony parson in any mpnner BOi�ER,BTU
so os ro become subject to the Workers'Compensotion Laws. AavROVAiS DAiE INSGFQOR'S SIGNATURE
Oafe Applicant 1 �MPRESSOR,BTt1 �W� O�I�-
�"ITICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM F�NAL Z.`ZZ'(�
mption, you should become subjecl to the Workers'
a.�mpe�apfion provisions of fhe Lo6or Code,you must for}h- EVAPORA7IVE COOLER VAIIDATION
with comply with such provisions or this permit shail be
deemed revoked- FURNACL FAU� p,,�I�y,�����
tICENSED CONTRACTORS DECLARATiON FLOOR BTII �uV�uV� �-O. O
I hereby affirm thar 1 om licenaed�nder provisions of Ehapter 4 HEA7ER� SUSPENOED UNIi_
-(commencing with Section 7000)of Division 3 af tha Business W'��
and Professions Code,and my license is in full force and eHett. `1 �`'`p �
13 Registers @ 1:75 � 22. 5 � � e � �
License Number �AOS14� Lic Class (,'-7n � i G V
I 4 �;;25 p
Contractor Ranr]l0 i2'� TIlm�,1e R—�l— Q
H
.giF�� = - �
� � _ �,
I am exempt under Sec. Plcn chetk fee d
N
8.8P.C.far Ihis reason p���T ISSUING FEE$ ���2�—�''' Z
Date: 10• �
TOTALFEE 53. 5
Signo�ure
OWNER-BUILDER DECIARATION PLAN CHEIX APPLICANT
I hereby affirm that 1 am exemp�fram the Contmdor's License �
law for the following reoson(Secrion 7037.5, Business and NMnE
Professions Code):
� I, as owner of the property, or my employees with AD�RESS
� wages as their sole compenwtion,will do the wark ond ��Tv TEL NO.
the slructure is not intended or offered for sale(Secrion
.J044,Business and Professions Code). pWNER
The Anden Gro
❑ I,as owner of the properly,am exclusively contrading
with licensed coniradors to construct ihe projeci(Sec- N'p'�� �.�7 Parkvie�,r Drive �2�1
tion 7044,6osiness and Professions Code). ADDRE55
CONSTRUCTION IEN�ING AGENCY Ciiv COV1D3� ��.No.818-967-95�+1
I hereby affirm ihat there is a construdion lending agency fo� ,
the performance of the work for which lhis permit is issued CONTRACTOR��Q�O ATR� j$L'.
(Sec.3097,Civ.C.). .... . _ . .
ADORES$ 1232 La. 9th Street �
lender's Name
c�rY uplana. TE�.No. 714-9g1-k8o
Lender's Address
�certify thaf I hava read ihis application and stote that the S�N�No. ��-98}-�►8e� CtA55
above information is correct.I agree to comply with all County
ordinances and Slate laws relating to b�ilding cons��uctian, 3$O�j2�3 (,'—'�Q
and hereby authorize representa�ives of this County to enter
�pon t o ve-meniione�property for inspection purposes. SEE REVERSE FOR EXPIANATORY LANGUAGE
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