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Home My WebLink About1016A WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PERMIT � � I hereby aftirm ihat I have a certificate of consenr ro self � insuie,or a certificole of Workers'Compensofion in5„�a��g, ,�1364c � HEATING - VENTILATING - AIR CONDITIONING- or a certified mpy thereof(Sec 3800,Lab.C.) CE-818(REV.10/81� � �P�olicy No.�`�6c"ompany Fai rmont Tna_ Cerrified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY � Certifiad copy a filed with the mumy building inspec- FOR APPLICANT TO FILL IN BUILDING fion depar�menl. � � AD�RE55 (PRINT OR TYPE ONLV) oo+e 5/29/87 qpP�i�a�� Rancho Air, Inc. LOCP'��rv Di NO. TYPE OF APPLIANCE OR E�UI7MENT FEE CERTIFICATE OF EXEMPTION PROM WORKERS' . NEARES7 COMPENSATION INSURANCE . CROSS Si. (7hls saetion nood no�6o eomplotod if hho work Involvad 6y Ag50RpTiON uNIT,aiu � oisTeia No. caocess�o ev The parmit Is for ona hundrod dollarc(;100)or loss.) qIR HANDUNG UNIT,CiM � I certify ihat in the performance of ihe work for which this j b � �permit is issoed,I sha�l not employ any person in ony manner so as to bemme subject to the Workers'Compensation Laws. BOILER,BiU qpppovnis Dnh iNsaecroa�s SiGNnTuee . �f""`� - 4pplicont 1 COMPRESSOR,BTU 27a 8OO - ZO OO ROUGH � ICE�TO APPLICANT: If, after making this Certifimte of VENTILATION SY57EM FINAL � � �( Exempiion, you should become subjecl to the Workers" , Compensation provisions of�be Labo�Code,you mus�forfh- EVAPORATIVE COOLER � VALIDATION . with mmply with such,provisions or this permit sholl be deemed revoked. � 1 FLOORCE: FAU�GR Y lo QO LICENSED CONTRAfTORS DECLARATION � I hereby affirm thof I om licensed under provisions of Chapier 9 NEATER: SUSPENDEO UNIT_ . �(commencing with$ection 7000�of Division 3 of the Busineu �'�'A�� :�'.� Q�,�� and Professions Code,and my license is in full torce and effecL . �' Re isters 1 +:�� • • �8 a License Number 380543 Lic.Class C'20 . , � '��2� �� Controttor R3riCh0 Air,IriC.Date a��-5�87 � � � � e c u�'U�� I am exempt under Sec. W Plan check fee p g��..�,b y B.&P.C.for ihis reason PERMIT ISSUING fEE S � Date: Signarure TOTAL FEE l�( 'Z � OWNER-BUILDER DECLARATION � PLAN CHECK APPLICANT � I hereby affirm tha�I am ezempt from Ihe Controctor's License , 1nw for Ihe following reason(Secfion 7031.5, 8usiness and NAME . � l Fassions Code): LJ I, as owner of the property, or my employees wifh ADDRESS wages as their sole mmpensotion,will do ihe work and � � the structure is nat intended or affered for sale(Section CITY TEL NO. 7044,Business and Professions Code). owrvea .The Anden Grou ❑ I,os owner of the proper�y,om exclusively contracting with licensed coMractors to construct ihe project(Sec- MAR � tion 7044,Business and Professions Code). F+�DRE55 CONS7RUCTION LENDING AGENCY CIiY �, n � ie�.nlD. _ � I hereby affirm fhat ihere is a construction lending agency for , � . fhe performance of the work for which lhis permit is issued CONTRAC70R Raneho Air ZI7 (Set.3097,Civ.C.). � . ADDRE55 . r� � - Lender's Name � � GTV TEI.NO. � Lender's Address — � I cerlif that I have read this o limtian ond slate fhat the STA7E LIG. � y pp LICENSE NO. Q 4 CLASS -C—'ZQ aba�e informotian Is corred.I agree�o mmply wifh oll Counfy . ordinonces and State laws relating to building consiruclion, and hereby authorize representatives of this County to enier . - . � - �u on the above-mentioned property for inspection porposes. SEE REVERSE FOR EXPIANAiORY IANGUAGE ,�,��,,,�D� s�t5�l5b— Signor�re of Applicant or Age�� e � ' -� � ��R� �6 OWNER-EUILDER DECL�RATION � � � I hereby affirm ihat 1 am exemp�4rom rhe Contraaor's � � � � , License Low for the following reomn (Section �031.5, � � ' �' " � �'-� � - eusiness and Prolessions Codei:Any city or covnty which t requires a permil fo consirucL aNcr,improve,demolish, � �� .� � �-� � - . � or repair any sfructore, prior fo ils issuonce, also re- � - ' , �� quiresihacppllcantforsuchpermittolileasi3nedstote- � � . . , mertt thet he Is ficensad pursuant fo the provisfons o1 fhe � Coniroctor's License Law(Chdpfe.9(commencing wihh � � �� '� � Sectlon 70Q0)of Division 3 of thc Bvsine-ss and Profes- � , sions Code)or tha�he Is exempt therefrom and ihe bosis - for ihe oileged e emption. Any violofion of Secflon . . _ � ` . 7031.5 by any opplicont for o pe�mif subjetfs the oppli- . � canf to a civil ponalty o/nof more then Nve�hurtdred - � � �- - , -� . dollors;S500J.: � � ' � ❑I,os owner of the property will do Ihe wor'a;ond � � � . . the srructure is nm in�ended or otfered far sale. � � � � � � - � � ($oc 7044,Business andProfessions Code: TheC....,rac- � � . . � ' � for's License Low does not epply to an owner of properfy � who builds o impro�cs ihPraon, cnd who doec sucb . work himsefl provided fhat wch improvemenfs are not - . � ' � intended or olfered for sale.i(,howeJer,fhe bulldirtg or improvemsnt is scld wifhin one year oi complefion,��he � ownsr-6Wfder vdll have fhe burden o!proving thot he did . � not bui(d or'rmprove(or ihe purpose of so(e.) - � ' � � �I,as owner of 1he praperty,am ezdusively mn- Iroding with li[ensed contractors�o con�irucf ihe project - fSec.7044)Business and Profcssians Code:7he Confrac- _ . � tor's Llcense Lau•does net apply to cn owner of properly � who builds or irnproves},tisreon,nnd who ton�rocts for � � such prajetts wi}h a tontractor(s)licensed pursuortf to . � � }he Con'racfor's!i[enso Law). I am exempt unde:Sec. B&P.C.for this reason � ' — Date . . .� .. . � . � Owner . iNSPECTOR'S NOTES } , � ,r; _. .' ;,• ., . __._:��. -., 5 . :,,.:.