HomeMy WebLinkAbout1030 N GOLDEN SPRINGS DR (9) ' woeKeas•connPeNsnrioNoeaaearioN � /�PP�ICATION FOR PERMIT �
I hereby offhm thot I hove a cer�ificate of consent to self � .
insure,or a certifimte of Workers'Compensailon Insvronce, �bA766C HEATING - VENTILATING - AIR CON�ITIONING
or a certified topy thereof(Sec.3800,lab.C.) � CE•018(REV.10/81) - � - - � ----
P❑olicyNo. F O�I3'I9ompany Fairmont _ .
Certified copy is hereby fvrnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed wiih Ihe county building inspec- FOR APPLICANT TO FILL IN Bl11lDING
lion deparfinenl. � (PRINT OR TYPE ONLY� ADDRESS 1 Q 3� N. G o 1 d e n S r i n s �R d
Dote Applicant `«""T''pi amond Bd P
. NO. iYPE OF APPLIANCE OR EOU�7MENT FEE
CERTIFICATE OF E%EMPTION FROM WORKERS' - NEnRE57
COMGENSATION INSURANCE CRoss si.
(Thl�sectlon naad nof 6a eomplefed ii fhe work Inrolvod by ABSOR7TION UNIT,BTU oi�Ri[T NO. VRO�FSSED BY
tha parmtt is tor ana hundred dollart(5100)or le�e.) � /�
I cerfify thol in fhe performonte a(fhe work for whith this F.IR HANDUNG UNIT,CFM �,/
permit is iss�ed,I shall not employ any person in any manner
so as to 6etome s�bjecl ro the Worke�s'Compensafion Laws. BOILER,BTU qPPR0VAL5 OATE INSiECiOR GNATURE
Oote Applicpnt � COMPRESSOR,8TU • ROUGH �a ao �
NOTICE TO APPIICANT: If, afler making fhis Cerlificale of VFNTIIATION SVSIEM FiNAt � ��
Exemption, you should betome su6ject to the Workers' . .
Compensation provis�ons of�ha Labor Code,you musl forlh- EVAPORATIVE COOLER VALIDATION
wirh tamply with suth p�ovieions cr rhis permit shall be
deemed revoked. � FURNncE: Fnu_ nw r
. LICENSED CONTRACTORS DECIARAT10N � � FiooR BiU � OO �
I hereby.affirm fhal l pm licensed under provisions of Chop�er 9 � SUSVENDED UNIT_
HEATER: WA��
'(commencing wBh Section 7000)of Diviston 3 of 1he Business ' }
ond Professions Code,and my license is in full force and e(fec�. 5 3 R e 1 S t E�"5 @ �1.7 5 9 7 5 � °'
litense Nomber 380543 lic.Closs C:-20 � • �
, V
co�,,o�,o, Rancho Air 8=31-83 - �
oo,e �
F
❑ . V
I om exempt under Sec. a
Plan check fee
B.SP.C.for ihis reason' �
PERMIT ISSUING FEE S j 50 z
Da�e:
Signo�ure TOTAL FEE 32 25
OWNER-BUIIDER DECLARATION PLAN CHECK APPLIfANT � �5 2&�3 A
I hereby affirm that I am exempt from ihe Contractor's License
Law for�he following reason(Section 7031.5, Business and NAME #� � �,� �$
i
'Professions Code}: . � �
❑ I, as owner of the property, or my employees wiih /+DDRESS � •3 2�2 5 -
wages as Iheir sole compensaiion,will do the work and CITY TEL.NO. ' � �
�he strocture is not in�ended or offered for sale(Sedion •'�J 2 J�C J c=i
70d4,BusinessandPra(essionsCode). , TH� ANpEN GROUP �
OWNER
❑ I,as owner at�he properly,am exclusively con�roding 0 1,1 3-8 3
w�ih licensed conhactors io constrod Ihe project(Seo- "'U`�� � - ' : - �-
tion 7044,Business and Professions Code). ADORE55
CONSTRUCTIONIENDINGAGENCY ��TMsan Dimas, CA - rE�."o. 599-6864 �
1 he�e6y oHirm lhot ihere is a construclion lending agency for �
the performance of the wark fo�which this pe�mil is issoed CONTRnCTOR -� --
(Sec.3097,e��.c.>. a n o i r- I n c- _. _ . . .
� A�DRE551586 Howard � ccess Rd. #D - � � � - - �
Lendei s Nome
arvU land CA TE�."o 981=4801
Lender's Address �
. STATE LIC. .
� I te��ify thol I hare read this applimtion and s�ote that�he LICENSE N0.3HOrJ43 - - -CLA55 �-2�. . ..-.. . . . ..... _ . _
obove informotion is torrect.I ogree to comply with all County
'n es and S�a�e laws relating�o b�ilding conslruction, . ' �
and �by outhorize represenrotives of ihis CouMy to eNer � � � � ' � � � -
po t ,above-mentioned properry for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE . . _ . _
Slgnnture of App n(ar Agen Date - . . - .. . . .. - . . .