HomeMy WebLinkAbout1019AWORKERS'COMPENSATIONI TION
APPLICATION
FOR
PERMIT
have a certificate of corse
I hereby affirm that I have a certificate of consent to self
insure,or a cbrtificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.)
_
76A364C HEATING •VENTILATING -AIR CONDITIONING
-
Policy No. F 21926 Company Fairmont Ins..
CE - 618 (REV. 10/81)
Th A nden Group
MAIL
ADDRESS
Certified copy is hereby furnished.
COUNTY OF LOS ANGELES
TELCovina. NO.
967-9541
BUILDING AND SAFETY
® Certified copy is filed with the county building inspec-
FOR APPLICANT TO FILL IN
BUILDING
TT I A TEL, NO. OA1 —h Aryl
tion department.
ADDRESS
450 Armitos P1.
Date 5/29/87 Applicant Rancho Air, Inc.
(PRINT OR TYPE ONLY)
LOCALITY
pjaMond Bar,
NO, TYPE OF APPLIANCE OR EQUIPMENT FEE
CA
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work Involved by ABSORPTION U
the permit Is for one hundred dollars ($100) or less.) AIR HANDLING
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws. BOILER, BTU _
ICE TO APPLICANT: If, after making this Certificate of
Exemption, 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 8/15/87
❑ I am exempt under Sec.
B.&P.C. for this reason
Date:
Signature
OWNER -BUILDER DECLARATION
I hereby affirm thI am exempt from the Contractor's License
1nw for the followiatng reason (Section 7031.5, Business and
/ essions Code):
LJ 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.).
Lenders 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 Stole laws relating to building construction,
and hereby authorize representatives of this County to enter
upon the above-mentioned property for Inspection purposes.
Signature of Applimnror Agent Date
1
VENTILATION SYSTEM
EVAPORATIVE COOLER
FURNA1 CE: FAU XX GR
BTU:!
FLOOR FyV}jV,�_ 10 0
HEATER: - SUSPENDED—UNIT—
WALL
USPENDED CbJt2S3 UNIT_
WALL
11 Registers @ 1.75 19 P5
Plan check fee
PERMIT ISSUING FEE $ 10 50
TOTAL FEE hO 717
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY
TEL. NO.
OWNER -
Th A nden Group
MAIL
ADDRESS
- 1074 Parkview Drive #201
CITY
TELCovina. NO.
967-9541
CONTRACTOR Rancho Air Inc.
ADDRESS
1232 W. 9th St.
CITY -
TT I A TEL, NO. OA1 —h Aryl
SEE REVERSE FOR EXPLANATORY LANGUAGE
NEAREST
CROSS ST.
DISTRICT NO. PROCESSED 1Y
c a APPROVALS DATE INSPECTOR'S SIGNATt1RE
ROUGH J p
FINAL
VALIDATION
:71 01.9A
4...
010,
o u 8
1 • 49,75
•.•49756
0£20-86
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INSPECTOR'S NOTES
INIFECTOWS NOTES
OWNER-EUILDER DECLARATION
I hereby affirmthatI am exempt from the Contractor's
License Law for the following reason (Section 7031.5,
Business and Professions Code). Any city or county which
requires a permit to construct, alter, improve, demolish,
or repair any structure, prior to its issuance, also re-
quires the applicant for such permit to file a signed state-
ment that he is licensed pursuant to The provisions of fhe
Contractor's License Low (Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Profes-
sions Code) or that he is exempt therefrom and the basis
for the effaced exemption.Any violation of Section
7031.5 by any applicant for o permit subjects the appli-
cant to a civil penalty of not more than five hundred
dollars ($500).:
0 I, as owner of the property will do the wed. -_and
the structure is nol intended or offered for sole.
(Sea 7044, Business and Profess/ons Code: TheCu,aroc-
for's License Law does not apply to an owner of property
who builds or improves therees on, and who dosuch
work himself provided that such improverreefs are not
intended or offered for safe. If, however, the building or
improvement is sold within one year of completion, the
owner -builder will have the burden of proving that he did
not build or improve for the purpose of sale.)
❑ I, as owner of the property, am exclusively can-
t -ting with licensed contractors to construct the project
(Sec. 7044) Business and Professions Code: The Contrac-
tor's License Low does not apply to an owner of property
who builds or improves thereea, ar;6 whocontracts for
such projects with a contractor(s) licensed pursuant to
the Contractor's License Low).
I am exempt under Sec
B & P.C. for this reason