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HomeMy WebLinkAbout0370A (4) WORKERS'COMPENSATION DECLARATION APPLlCATION FOR PERMIT � / I hereby aff rm fhaf I have a cerf fiwfe.of consent to self �� - � � � . .. . ...... . . ....... ,,... .. . , , . . insu�e,or a ce�u4icate of wo�ke�s'Compensmion`insu�ance,"' �bA3aac HEA�`�NG -�V�ItiCTIYAYI�HG - RIR CONDITIONING or a cer�ified copy thereof(Sec 3800,Lab.C.) � . _. . ... . . .... „ ..._:,:.: , .. ....;..... ,_.., CE-818 fREV.10!811 . . - .... .,_., � rou�v Nd^JC51539�+ compo�YUni�ard Ins. Q Certified mpy is he�eby fu�nished. . GOUNTY OF LOS ANGELES BUiLDING AND 5AFETY _. ��. , ., .. .. _. Certif'rad co s filed with�he.count -build'rn � - �— �- ��-- .�_. � py� y g inspec- FOR APPLICANT TO`FIi:L IN � � euunwc, noo dePo�i�„eoi. �PRiN?oR rvice orvtvi nooaess 2�+�+39 E. Deepsprings Drive ,_. Ddte 5-?9-p�y_Applican�RANCHO ATR� TNC. �ocaurr Diamond Bar NO. TYPE OF APPIIANGE OR EQUIPME'VT FEE � CERTIFICATE OF EXEMPTION fROM WORKER$'- � NEAREST �� `-� COMPENSATION INSURANCE � � �" � �� ` � -���-� "�"�` CROSS SL Tra,C'� �{36 LOt �I2 '�'� '' ''� A850RpfION UNIT,3TU (Thia se¢ion need_not be compleTed ii Yhe work�nvolved by oisraicr No. - fhe permit is ior one hont�red dollars(5100)or less.)� � � � � ����� �"' I certify ihal n fhe performance of the wo k for which�his AIR HANDLING UNIT,CFM � permii is issued,I shall not employany�person n ony manner � -��' so as to be<ome subject to the Workers'Compenwtion Laws. BOILEe,Bru . ,nPPR�v,a�s onre wsaecroa�ssi�varuRe ..... ....... ..____...,.._..,:_..__..._..__.._„ 1 COMPRESSOR,BTU�� O�O � �` Applicont � lO OO ROUGr+ � _.....---.....:-- .,,iICE TO APPLICANT: If, after making this Certiflmte of VEMiLATioN5Y5iEM ' FINAL - � � Exemption, you should 6ecome�subjed to the Workers' � . ... ._.......__,.....___-�.__. Compensotion provisions of rhe Lobor Code,you must{orth- eva?oRa'roE coo�.ER VALIDATION with corriply ith such provisions or ihis permit shall be � � � � � w deemed revoked. FURNACE: FAU_G VITY � � . IICENSED CONTRACTORS DECLARATION Z P�OOR -BTU ��� ZO OO __.. I hereby affirm thol I am licensed under provisions of Chapter 4 �- SUSPENDED � ��- 'JNIT"""^ -(commencing with Section 70001 of Drvision 3 of Ihe Business HEATER; WA�� � . and Professions Code,and my license is in.full force ond effed. � -""'"��"������-'^��•--'���•� y . � ucense Number 380543 ���.��ass C-20 1 R 1 ' V Contracro� ��TCHO ASR� INCpb�e 8 31-87 � ❑ .... . . ........ O I om exempi under Sec. 4d . .. . . . .. ..., . W Plan check fee �, B.BP.C.for this reason . y� _. " " PERMIT ISSUING FEE S 10 50 „ - � oqre: 1+�,5 i,�A — Signat�re 70TAL FEE �>'_�% ,,, , . .. ... .._.,. ....,. z;,. :: e o c L . ....._._.... ,,.�....... ,.... OWNER-BUILDER_DECLARATION � P.Ary CHECK APauCANT I hereby afFirm thof I om exempt from the Cont octor's License . . ....,. _„_,,. , ► ( s �� -��,� .,. .. �...,.�...,:.....::. , �+p10`�N for the follow.ing reason(Secrion 7031 5, B�siness and NA.b1E � ^y� iessions Codej:� � �� , , _ � „ ,�" UI, os owner of the propeny, or my employees with ADDRE55 ^ _ _ .. C 1::'i0-87 wages as iheir sole compensation,will do the work and � �������'�""�• -�--�•���� �� --^•���-� the structure is not iniended or affered for sale(Section CI7V iEL NO. . 7044,8usiness and Professlons Codei," '�� � � � � .,.-._.,.,. _:::�,_.,.._..,... � owNeR THE ASdDEN GROU° with Ilcensed cont actors to mnstrulusively conhqcting ��- � , ...,ct the project(Seo- N�AIt �. ., � . .. �....::.�...-.-�.� �ion 7044eBusiness ond Profe s�o�s�co�`e>:�� -� � Aooe�s97�+ Parkview Driye #2�1 . CONS7Rt1CT10N LENDtNG AGENCY � � ��'- -`' -"-��``� _ . a�"ovina E�q�7-95�+1 � I hereby offirm thot ihere is a construct o�n lend_ng agency for , , .... .. ..,..... ...... ..,: ihe performonce of the work fon c�h this permi�is issued CO�ViRaCiOR (Sec.3097,Cw C.). � RAETCH AIR INC - ADGRE55 -�� � Lender's Name . . . _.. _....... . . .. �e�ders address ary Upland rr� "0 981-95�+1 � . . ... ...... ... STATE 1'.. . ., .......LIC ._.....,:.. .....�:,,_.....,....,�. I cert�fy that I have read this application and sfote thaf ihe LICENSE NO. 380 y� CLA55� �G' 'ZD above information.is,correc(.I agree to comply with all Co�niy� . ..... ._ .,. ., o d nances ond State I ws�reloYi g to building construction, � � � � '- �` � � a d her by aut�e��presentoi es ef thi5 County fo enter p n t e above ent ned prope ty for inspe t on purposes. .,a E.-s� �T .-, r.�,�„ � -SEE REVERSE FOR EXPLANATORY LANGUAGE o ,� . ...... . ...__,....,..,. ... . _,.. ._...,.. ..... ... .. ....,.. .. .� n �i.^i" � ..��.; _��...i`�' . . ._. . . .., . _ . 5g 't�.,re of Apoli nt or Agenr D e �L � � . _. . , IWS��Y�R'S�f�TES ` d1NfVER BUILDER OECLkRATION' .. ... .._ . ..:.. - -. '� here6y�a4fir.n 4nof I cm exenpt:rom ih=Con±racior's � � '�� � � � -- � � - - Lkens� I. 4 or fh . I ow�eg reoson ;Sec�ion 7D37S . . ... . .. . . . . . . .. . ... . . eus'rr�e d P o`es or ode��Any ci;y er rour�ty•.�n ch , � .: „ � . . - � - � - � ' ��requires c per,'oit�,o onsi uct;crfier,�improve,de�rolish, -- -�- � � � � � - � - � � � or repair any structure, prior to its issuanco, a7;o re - - � ,....�. quires fhe applicant for su�h permi;to.file q slynexd sfoSe- �- � . .. - - � � � � � � enf tn i he is lrrens�d,porsuant fo tbe��cvisions o4 i6e � „ , . � . � . Cav�c•ors L!rnnse�I�ow;Cbdpt�r 9(commencir,g wi!h , ���- - �� , .� � - � � � � � � � � - � Secficn iuon�o!D�vs�or 3 of the�usi�ess and Profes- � � sions�CcdeJ or iha�he is exempt the•�re£rom ond fbe basis � - � � ! � thc alf-ged�exsmp�ion.�F,ny vialcPion of Sect"ron .__. _. _ �._ . . . . ,,._...,. __. � � 7037.5 by eny appficant for�permit subje.is th��op�nli- ant fo o cryii pei�alfy of nci more fhan five hundred . . .. . . — dollars�,`5500;.� . . . � � � ��-� ��� �J I.es cwner o'tFa preperiy v✓il.do the�mc"`^and -� ��' ���� � �� � �� �� ��� � � irrended or offered for scle. � � ��' � � -� the struc'ure i;not . . '� � - .� � � � �. � . . . - � . �� � - (Sec.7044,5usinassondProfesstonsCode: TheCcntrac- _.._ . .__... .,:... .. . .,.. .. . . �.... . . � , tar's License Lav�does not cppfy to on owner of properiy �� �� � who builds or L7;�rcvrrs fi�erecr�, ond v+ho does s-uch - . .. �� _ � ark himself provided 4{io9 such improvem^nfs are nof - � � irt�nded or olfered(ur scie.If,however,fhe buildir:g o� . .. , improvement is-scfd within-on�qear of compfe"ion,iL•e � � � .. - - .- �� � owner b�fder will hove i4,burden,of proving fhat he did . ......_..., .. . . �� not build or improve for iha pu:pose of sale.l �� � . ,. . �J 1,ps owner o�ihe p'ro�eYty,am exclusively corv� ,rading wi'h licensed c acicrs tc ��=.nuc'ihe Frcjec+ .. (Sec.7044)13usiness cnd^Profassions'Code:T»c Cor,frcc- � 5or's License Law docs not ooply ib cr owne�of properiy whc Sui(ds or improves ihereon,and wY,o roniracts for . �� - soc6 projec i wi4h a ton;rvtpor(s)ficensed pursucr,f to - - � fhe CoR}f¢C/or5 I_iCehSe LCW)�.' ' ' � ':am exempt under Sec. � B&P.C.for this reasan—_� _ . .. . . ..._ . . . .... . . .. . ' � . �. �. .. Date— ---�—. ,. . . � : � . . . . -.- . � . . . ..4�wner � � .... .. ... 1T35PECTOR'SNOTES ,,. _ ..,,..... ..�.., ., ._._.... �.. . .. . . .. . .. _ ._._ . . ...