HomeMy Public PortalAbout6210 GOLDEN WEST AVE_Mechanical__ WORIKERS'CnMPENSATI,ON DECLARATION �° 7,6A364C - - o_. ,/�
I sereby a'firm that' I"'have�a certificate of consent to self -CE-818( -80), �'� ds II U Cl ®� �'llVlf��
ro
` insure,or a•cert ftcate of orkers'Com ensation Insurance,or '-
a certified,copy thereof(Sec.:380 L bpC � -° '�r. DIEATING-b��`��I�l�tlNGrA163 CONDIYIONIkOv
Policy No' - Company ' " <O L"OS�Af1I,GELE �
4.;= ° .,COUNTYxF' , S BUiLDIiUG•AWDSA�ETV
Certified copy js'hereby furnished. i ,y
erti6ed"copy is filed i ith the county,bi' i r M gUILDING`r�
denar'rrie f L FOR�APPLICA'iV7 TO.FILL' IN
�(PRINT'OR TYPE'ObNLY) ADDRESS
Date / Applicant – — r f t
LOCALITY �z ��
CERT FICATEOFEXEMPTION .ROMWOR.KER$" t" 'NO T-YPErOFAPPL"IANCE OR'EQUIPMENT,- FEE' y «'
COiv1PENSATION IN5URANCE'; `i . ; y. NEAREST � � r� -,r >
��� �� CROSS ST. ;�a C..•
(This,section need`rlot be co 'pleteWjf the"wolkinVolved " �. ABSORPTION UNIT,,B U O
bY the permit_.ls".for`oAe hundred_d011�ars i($IQO) OI less.)�_, "k _. -`, _ _ ;]STRICT NO- " , PROCESS BY_r_ _ (�
I certify'that in�the performance of the work for,`whicli,t[tis a - AI,R HANDLING••UNIT,CFNF'