HomeMy WebLinkAbout0649A vv�rcxtKs'COMPENSATION DECLARATION APPLICA�ION FOR PERIY`IT � �
1 hereby affirm that I have a rertificote of consent to self .
insu�e,or a ceruiicate of Wo�ke�s'Compensafion Insurance, 76A364C HEATING - VENTI.IATING - AIR CONDITIONING
or a certified copy ihereof(Sec.3800,Lob.C.j ,
CE-818(REV.�Oi81?
P❑olicy No._F�l Q�tompany F2 i rinop'- Tns_
CertiFied copy+s hereby fumished. C�UNTY OF LOS A�VGELES BUfLDING AND SAFETY
� Cerfifed wpy is f�led with the counry building��sPec FOR APPLiCANT Tp FILL IN suaoiNc
fion deparfinent (PRIN70R TYPE ON!Y1 AODRESS2�! 6 r
ome S�29j87 Applicont xancho Air, Inc. �x''��T�Diamond Bar A T-
NO. TYPE OF APP!IANCE OR EQUiPMEM FEE
CERTIFICATE QF EXEMPTION fROM�WORKERS' NEAREST
COMPENSATtON WSURANCE CRasS 5T.
(TMis seeHon need not 6e cumpleted if the work Mvolved by AeSORaT10N UN�i,aTu oisrz�cT No. v�ocesseo ev
fhs permit is for one hundred dollon(5100)or less.) qiR Ha.NOL�MG UN�i,CPM
I certify thot in the performance of the work for which this . - (� �-�
permit is issued,I shpll not employ any person in any mqnner gOILER,e7U
so as to become wbjeci to tF�e Workers'Compensation Laws. aPaeovau cA;e iNSPEc*ce�s s��cNa�cee
��•�.� Appl�ca�� � coMaRessoR,eru �8�000 10 00 Roucr. � ,r"�t"�+ P�d'',$�
" 10E TO APPLICAN7: If, after making this Certifimie o4 � 2 vENTiLATiON SYSiEM 1Z QQ FINA! ��.�.'
h.emp�ioo, you should become s�6ject 10 fhe Workers' r
Compensation provisions of the Labor Code,you musl forth- EVAPORATIVE CODLFR vA�I�AT�ON
wiih comply with such provisions or �his permit shafl 6e
deemed revoked. - FURNACE: FAU_GRA�IIY
LICENSED CONTRACTORS DECLARAiION •- FLOOR siU L1U>��U�7U—� �O OO
I hereby dffirm ihaf I am licensed under pravisions of Chapier 9 ryEytEp: SUSPENDE� UNIT.�
(commencing with Seciion 7000)of Division 3 of�he 8usiness � �vA« <�,
and Professions Code,and m license is in full force and effed. -`� �
Y i3 Re isters � 1.7 2 �,�p p
C-20 `:' �=� �
License Number 3e�05�3 Lic Class ' �� �'' �.
c .' -)4-c
Contractor +�ar1C'f10 �.'i yTIlC.Dote �����87 � � �� � �" �
❑ 1 C1
I am exempl under Sec. ��t�� < <%Y��' �
Plcn check fee
B.&P.C,fo�this reason �
PERMIT ISSUING FEE$ 1
Da�e:
Signaru.e iOTAI FEE 6 2
OWNER-BUILDER DECLARATION P�AN CHECK APPi�CANT
1 hereby affirm that I am exemp�from ihe Coniraciar's license ,
Law for ihe following reason(Seclion 7031.5, Bosiness and N.WnE
�"'"�'`essions Codel: �
u �, as owner of fhe property, or my employees wifh AO�RE55
ages as iheir sole compensdtion,will do the werk and �ITY TEI.NO
fhe structure is noY intended or offered far sale(Seciion
7Q44,6�siness and Professions Code). GWNER
❑ I,as owner of ihe properry,am exdusively coniratling T�"1 A d-
wifh liwnsed coniraciors to toosr�uct fhe prpjed(Seo �'�'A�� i, �
tion 7044,Business and Professions Code). ADDRESS 10 4 1�8,^�S.V12W .�TiV2 `2�l
CONSTRUCTION LENDING AGENCY ��T�� COV1P$ TEL Na. �6 _ �y
I here6y affirm ihat ihere is p construction lending ogency ior ►
the performance o4 ihe work for which this permit is issued cO�+TRaCTOR
(Sec 3097,Civ.C.j.
aooeess 12�2 t�J. th St.
Lender's Name ��
Lender's Address C�TY U land TF�.N�. 7--� 03-
STATE 1' LIC.
I cerilfy thal 1 hove read ihis opplimtion and state that;he LfCENSE NO. Q �+ CLA55 O—`�Q
above information is corred.1 agree ta comply w�ith ol,l County . .
ordinances and State laws relvting�o building consiroction.
and hereby a ze represent tives of this Couniy ta en}er
upo ab e � ases. SEE REVERSE FOR EXPLANATORY LANGUAGE
�f
Signolure o Apo�icun A9a�t �e ,
9Pi5PE�TQ�'3 Po14TE� —�_� OVJ�ER-3UIL�EiZ JEG�FaRATIC)N
. � hereby af+irrn thct I om exompl{r�m'he Conir�ctor'a
� � License I.aw for the follo�,ving reascn (>oc!icn ?G31.5.
. . . . . . ., _ ,._._.,...,.. Eusiness urd Frofassicns�odei:Ar,y,_i;y cr muniyv�hrcf;
' � reqerrres a?errrrif b ccns.'-uat,ol;er,imprcve,dcmolish
- - � ' __ or ropr.ir ar,y's4ru<fu;e. pria-io rfs rssuanas, plso rc
. qoires 1he o,upUcanF for such pe:mit�to file u s7�rrad stete-
rnenf fhct Fe is fic�rsed pursuuttP ta}he prouisions of;L-c
, � '- Ccr„rodw�s Liczrss�Law'Cnap,er 9;cum•:iendn3 wrL�
� Se;tion 7�Ofij of i;rvisicn 3 cfi 1,`,=3us:nas��nd FYc?es-
� sions Codej a tho�ne is�r.crnp;ihe;refrorn on-u'the ca,i::
for Ina olley� ex�.-prion Any vicia':on of Section
' . � 7D31.5 by ary c�pliccn.`for a perm;f sub�ecls ihe cppii-
- � cant io a .^lvil�:,.enoii�o`naf more fllan five hundre-d
� - � c;a!lars(5500'�,.
. � . .... , ,, oi tno��ropeny�.v'!i;o�h�•:;ork ond
� .z� ...
.��;: . � . �he a,�uc;ure isVnotri�rerided nr ot:`ered for salm ' '
� ' ' '' - (Sec 3094,6usin_-,s on�Ptofesslons Coder �Thai_ rac-
, � . �ar's Licensa Lev✓doe::nof epply��o on owncr e¢property
. v+ho i vilds c> improvEs thareon, ond who doas such
, -. -------�-- v�o;k hi.�sal¢providsd that suoh improvsments are r:ot
� .ande;!or o�`fared ior sale.H,howevzr.:na builu'!ng c�
� � - impr�ve�'nent is sofd within c•^.e yeor or com,n!eiian,ihe
' ewn2:-bu"rldcr wiJ7 have fbe burden o1 provir.g that he diJ
. r.ot bui(d or improv�for 9hc ourp6se of sslm.)
�_,_, __�_ ❑f,os cwr=r of ihe procar,y,nm exdusively cen-
t-�c•i!-,y�„lih ii�^.sed con'rc:tors b cons4:uc:d�:e nre ec•
___ _ _______ _____ ;Jac.7C4.f1 ausiness and Profcssio,as Coo'e�Yh��Controc
� To:`s 6r.ensa Lc�,v dces r.ot appfy fo cn c::mcr o7 property
_ v,rho nui(�s or improves ilieron,nnd wFa contrnct;fo.-
� such prejec9s vri4h o co�afrac7ur(>i licensed pu.��uanf ic
_� 'he Contractor's Lieertsa Lcw;.
—�— ----'-- — i a;n cxempf under�ec ---.----
� - B&P.0 for this reasor,_ —`_� _
Date_��.-- -------
Owner_ ---
9N�PEC70R'S Tl�SES _