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Home My WebLink About1017A WORKERS'COMPENSATIONDEGLARATION APP"CATION �OR PGRMIT � I hereby af#irm that I have a certificate of consent to self . insure,or a tertifimte of Workers'Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING. or a certified copy thereof(Sec.3800,Lab.C.) CE-BI B(REY.10/81 J � P❑olicyNo. F 21�26Compony Fairmont Ins. � � Cenified copy is hereby fumished. COUNTY OF LOS ANGELES BUILDING AND SAFETY � Cer�ified copy is filed with ihe counry building inspec- . FOR APPLICANT TO FILL IN BUi�oiNG :.�' tion department. aoDRE55 �y 6 it P (PRINT OR TVPE ONLY) Date 5/29/87 Applicont Rancho Air, Inc. LOCAIITV Diamond Bar CA Tract 42 6 NO. TYPE OF APPLIANCE DR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEARE57 COMPENSATION WSURANCE � CROSS ST. (This�aclion noed not ba eompleted if ths work involved by . ABSORPnoN UNir,erU DISTRICT NO. PROCESSED BV fhe permlT Is for ono hundred dollara(5100)or lets.) AIR HANDLING UNIT,CFM A 1 certify that in ihe performance of the work for which this �(� Q.Y . permit is issued,I shall not employ any person in any manner � so as�0 6emme subject�o the Workers'Compe�safion Laws. BOILER,BTU -nPvaova�s oa� WSPECIOR'S SIGNATURE �� oPP�.�a�� . 1 COMPRESSOR,BTU 27�Ann ZO OO ROUGH JCE TO APPUCANT: If, after making this Certificate of VENTILaTION SYSTEM FINAL Q� Exemption, you should become subject to fhe Workers' . Compensation provisions of the lobor Code,you mosf forfh- EVAPORATIVE COOLER VAIIDATION wilh comply with such provisions or this permit shol��be � deemed revoked. � . FURNACE: FAU XX GRA Y - � � LICENSED CONTRACTORS DECLARATION 1 FLOOR B7U ZO OO � I hereby affirm ihai I am licensed under provisions of Chapter 9 . SUSPENDED UNIT_ � � �(tommencing with Section 7000)of Oivision 3 of�ihe Business HEATER: �,A�� and Professions Code,and my license is in full force and effect.- � � c�O��7 A a License Numbar 3805�+3 Lia Clpss C-2� �� r 8 V Contractor_RBriC$O Air,Inc aare 8/15/8'f , I � a 4�2 5 � � � o �4G.25�� i I am exempt under Sec. Plpn CheCk fee . G�F 2 C�'S 6 y 6.8P.C.for this reason pERM1T ISSUING FEE$ ? Da�e: 10 0 5gnature TOTAL FEE - OWNER-BUILDER DECLARATION rV+rv CHECK AaPUCAnT � � �hereby affirm that I am exemp�from ihe Conirac�or's License _ , taw for the following reason(Section 7031.5, Business and NAME . � � Ifessions Code): � � I�I I, as owner of the pfoperty, or my employees wifh ADDRE55 wages as iheir sole compensation,will do the work and ihe siructure is nof intended or offered for sale(Sectian GI7V TEL NO. 7044,Business and Professions Code). OWNER The Anden Grou � � ❑ I,as owner of�he properry,am exdusively contracting wifh licensad coniractors to cons�ruct ihe projetf(Seo- MAIL � tion 7044,Business and Professions Code). ADDRE55 CONSTRUG710N LENOING AGENCY CITY � 7EL.NO. 6 — �Fl . I hereby affirm that there is a construction lending agency for ► � the performance of the work for which�his permit is issued COMRACTOR (Sec.3097,Civ.C.). � 1 - ADDRES$ . � Lendei s Name arv U land re�.No. g1—�4801 Lender's Address . � I certif that I have read ihis a licotion and state that the STATE LIG � Y pP LICENSE NO. aO 11 C1A55 C-2O -- � above informotion is carrect.I agree to comply with all County � � _ , � � ordinances and State laws reloting to building conslruclion, and hereby authorize representa�ives of ihis Coonty to enter . o an the above-memioned property for inspection porposes. SEE REVERSE FOR EXPLANATORY LANGUAGE � s� s-� �.��_ Signofure of Applicant or Agenr poie ' . I ECTOR' OT� OVJNER-€;UILDER D�CLARATION - � - . � � - I hereby offirm ihot I om ezempi from the Confractor's � � - License Law for the 4ollowing reasen (Sectio� 703I,5, . � � � � � - � ' � BusirtessandProle:sionsCode7:Anycifyormuntywhich . � � requires a permlt to construcG ol�er,Improve,demofish, � � or.rep¢ir any sfruc�ure, prlor fo Ifs issuance, also re- � quira,tha applicont for such permil to file o signed s�ofe- � � � � � � ment that he is licensed pursuont to ihe provisions o!iRe �. . � Contrecfor's License taw(Chapfer 9(commendrtg wiih � � . � Seclion 7000)of Division 3 of ihe Business and Profes- � sions Codej or thaf he Is exempf therefrom and fhe 6asis . , . � � � � Ior tha olleged exemption. Any violation of Secfion . . �. 7031.5 by any appfiront for a permi�subjetis}he appll-� ' . - � �� coM lo a.civil penolty of not more than flve hundred .. . . . . . dollars(ESOOj.� _ � _ - . : � ❑I,os owner af rhe properry will do the wor�—.and � � � � � - . �he srructure is nol intended or offered for sa�e. � . - (Sec.7044,Buslness and Professions Code: 7he C��rrac- � � � � . ' tor's Litense Caw does not apaly io on owner of proper}y v�ho buildx �mpro s fhereon, and who does such . , . . � wo�k himseff providedefhal such improvemenis are not � intended or oHered for sale.If,howevar,the buildfng or � � . � �. improvemenf is sold wlfhin one yeor of compfstion,}he - � ownar-6uifder wf(I hava the burd�n olproving thol he did . � . � not build or improve(or�hc purpose of scle.) � , ❑ I,as owner of the property,am exclusively con- � � +rouing with licensed mr,trac!ors ro mnstruct!h�projec' � (Sec.7044)Husiness end Professions Code:The Controc- � . � for's License!cw does not opply lo m�owner of proper�y who builds or improves thereaa,wu.'wFo rontrads fo� � such pro�ects with a tontractor(s)licensed pursuani to ' Yhe Cantrccb�s Li<ensc LawJ. � - � I am exampt under Sec. . � . 6&F.C.for ihis rea��on � � _ � � . . . Datc � . � . . . . . Owner ' . INSPECTORS NOTES' � . :' :��_, t .r,�,, _. � _ «�''.r<''�