HomeMy WebLinkAbout0614A (6)WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure,; or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy Na. F 21926 Company Fairmont Ins.
Certified copy is hereby furnished.
® Certified copy is filed with the county building inspec-
tion department.
Date 5/29/87 Applicant Rancho Air, Inc.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work involved by
the permit is For one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
per is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
C' -`e Applicant
ICE TO APPLICANT: If, after making this Certificate of
nemption, you. should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with. comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
'(commencing with Section 7000) of Division 3 of the Business
'and Professions Code, and my license is in full force and effect.
License Number 380543 Lic. Class C-20
Contractor Rancho Air, Inc Date 8/31/87
❑ I am exempt under Sec.
B.&P.C. for this reason_
Date:
Signature
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
`essions Code):
u I, as owner of the property, or my employees with
wages as their sole compensation, will do the work and
the structure is not intended or offered for sale (Section
7044, Business and Professions Code).
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby. affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon above- m nt' ned property for inspecti5vpurp5p6s,
Signature of Applicant or Agent Da
APPLICATION FOR PERMIT
76A364C HEATING - VENTILATING - AIR CONDITIONING
CE - 818 (REV. 10/81)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
(PRINT OR TYPE ONLY)
BUILDING
ADDRESS2423
E. Sylvan Glen Rd. Lot
LOCALITY ,
NO.
TYPE OF APPLIANCE OR EQUIPMENT
FEE
NEAREST
CROSS ST.
ABSORPTION UNIT, BTU
DISTRICT NO.
1
PROCESSED BY
AIR HANDLING UNIT, CFM
BOILER, BTU
APPROVALS
DATE INSPECTOR'S SIGNATURE
1
COMPRESSOR, BTU 36 , 000
10.00
ROUGH
3
VENTILATION SYSTEM
18
U
00
FINAL
-2,0.
EVAPORATIVE COOLER
VALIDATION
''0.61.4A
Io®61—!25
i 4 8 6
1
FURNACE: FAU GRAVIT
FLOOR BTU
10
00
HEATER: SUSPENDED UNIT
WALL
@1
15
75
_Registers
Plan check fee
PERMIT ISSUING FEE
10
50
TOTAL FEE
64
2
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL. NO.
OWNER
MAIL
ADDRESS 1074 Parkview Drive #201
CITY Covina TEL. NO. 967-9541
CONTRACTOR Rancho Air Inc.
ADDRESS 1232 W. 9th St.
CITY U-Qland TEL. NO. 1-4801
cJ
STATE LIC.
LICENSE NO. 380543 CLASS C-20
SEE REVERSE FOR EXPLANATORY LANGUAGE