HomeMy WebLinkAbout1003A WORKERS'COMPENSATION DECLAR.4TION APPLICATION FOR PERMIT �
I here6y affirm that I have a certificote of consant to self . ,
insure,or a c�rtificate of Workers'Compensation Insurance, ���4� HEATING • VENTILATING • A{R CONDITIONING
or a certified copy�hereof(Sec.390D,Lab.C.) . .
CE-818(REV,ld/81� .
�cy rvo. F 21926company Fairmont Ins.
Certified copy is hereby fornished. COUNTY QF LOS ANGELES BUILDING AND SAFETY
a Certified copy is filed with the counry building inspeo FOR APPLICANT TO FIIL IN BUILDWG �
rio�de a�+�„e�c AooREss 1+68 Armitos Pl. ot 27
P (�RINT OR 7Y7E ONLV)
oare 5/29/87 qPP���p�� Rancho Air, Inc. iocnurv Diamond B r A Tra t 42 6
NO. TVPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' . . NEAREST
COMPENSATION INSURANCE CROSS ST.
(This�seclfon need nof ba complafad if the work involved by ABSORPTION UNIT,8TU DiSiRICt NO. ' PROCESSED BY
fhe permif fs for one hundred dollars(5100)or less.)
.1 certify that in the performance,of ihe work for which this AIR HANDLWG UNIT,CfM �D �d.
permit is iss�ed,I shall not employ any person in any manner goaeR,0Tu d'
so as to 6ecome subject to�he Workers'Compensotion Lows. APPeovAlS DAiE iNsvecroa�s si�NaTuae
f^'h Opplicpnf �- COMPRESSOR,BTU 27.SDO �..0 O RpUGH
ICE TO APPLICANT: If, afler making,ihis Certificme of VENTILAT�ONSVSTEM F�NA� Q�+
Exemption, you should become subject to the Workers' �
Compensation provisions of fhe Labor Code,yau musf forth- EVAPORATNE COOLER VALIDATION
wi�h comply with such provisions or this permit shall be �
deemed revoked. � � FURNACE: FAU�GR Y ..
. LICENSEO CONTRACTORS DECLARAiION 1 FIOOR Biu �.O O
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER:� WA��NDED uN17_ `,� O Q 3 A
'(commenting with Sectian 7D00)of Division 3 of the B�siness .
ond Professions Code,and m license is in f�ll force and effec�. ' �'
Y Re isters 1. 14 0 �•' •� •a p
License Number �� ��_Lit.Closs� � , I ,.�.�5 O �
e • i
Contractor RanCho AiY'�Inc.Dare 8�15�87 ��, = O
O <•4[�5�� �
I am exempt under$ec w
Plan check fee D�2 d�8 6 y
B.&P.C.for this reason�
PERMIT ISSUING PEE; �
Da7e:
10 0
Signature TOTAL FEE 1{1� p
OWNER-BUILDER DECLARATION � v�nN CNecK nPauCaNi -
� 1 herebyaffirm that I am exempt from 1he Controcror's 4icense ► �
�w for the following reason(Section 7031.5, Business and NAME
`essions Code): � -
LJ I, os owner of the property, or my�employees with AD�RE55 .
agesostheirsole,mmpensafion,�willdothew6rkond Ci7Y TEl.NO.
the siructure is not iatended or offe�ed for wle(Sec�ion
7044,Business and Professians CodeJ. � � �
OWNER
❑ I,as owner of ihe property,am ezclu5ively mntrdcfing
wilh licensed coniraclors to constr�ct fhe projec�($ec- MAIL I�
fion 7044,Business and Professions Code). AD�RESS ZO74 P3P�iV12W DY'1VQ �201
CONSTRUCTION LENDING AGENCY � ciiv TEL NO. L _ 1,l ' �
I hereby affirm thai there is a construction lending agency for o `� � '
the performonce of the work for which ihis permit is issued CONTRACTOR
�se�.soe�,c�.c.7. Ranch Air I c.
ADDRESS 1232 W. .tYl S.t. � � � .
Lender's Name
c�rv U land rei.No. 981-4801
Lender's Addre3s
STATE UC. � �
I cerfify thot I hove read Ihis application ond stote that the tICENSE NO. ClASS
a6ove information is m�red I agree�o comply with all Caunty
ordinances and Stale lows relating to building conslruction, �
ond hereby au�horize represenlarives of 7his County to enter
n the above-men�ioned property for inspection pwposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
o�'�.�—
Signature of Appliwn+or Agent . �ate � . � � �
1 ECTOR'S NOTES OWNEF:-GUILDE�DECLAP,ATION �
. . I�hereby a#firm ihnt I am exempi 4rom�the Confrdctor's
License Lo.v For th= following reoson-(Sedibn 703L5,
� ' �� - � � Business ond Fro(essions�od�n;:Any city or counry which
- �requires o permif to construct aher,improve.demolish,
- --' � ' pr refwir eny structure, prlor fo ifs issucnce, olso re-
� � quires fhe opplicant for such permit ta file o eigned state-�
� -� �� , � � � � ment}haf he is(icensed pursuanf fo the provisions of the
� � Contractor's Lirense Caw(Chopfer 9(commencing wifh
- � �� � - � � Sectlon 7000J o/Division 3 0�fhe Business and Proles-
� � sions Codej or}hat be Is exemp�fhere{rom and ihe 6asls
for the allcge� ezempflon. Any violafion of Section
... ..._ __ .. 703L5 by any opplicani(or a parmit subjeUs Ifie oppli-
- � � � .cant to a civil prnaliy o(nof more than five hundrod
� . - . - � .. . . dolfars(5500).:
- � ❑I,os owner of the property wlll do the work,ond
, � ' . ihe siructure is not intended or offered for sole. -
� - , -� � � - � - � .. (Sec7044,�8uslnessondProfessionsCodc: ihoC�..�rao-
, . - � � �tor's License!ow does no/opply to an owner of property
. � - - who 8utlds or improves therenn, nnd wMa does such
� . � work himseH provided thal such improvemenh are no�
. � - rnfonded or o`fered(or sole.If,howrver,fhe bullding or ,
� . �improvement is sold wifhin one year ol completlon,the
� owner-builder w(U have fhe 6urden ofproving that he did
� , � not 6uild or improve for thr�purpose of sale.J
� . � " � � ❑I,es awner of the property,am exdusively con-
� . tractlnq with licensed contraciors re mnstrucr the project
- � � , (S.ec 7044)Business and Prof�ssions Codn:ihe Contrac-
� ror's License Low does nol oppiy fo on bwner of property
who 6uilds or improvcs the;ean,cnd who controds for
such projects with a confractor(s)licensed pursuanf to
fhe ConTracfor's License Law).
' - I am exempt under Sec A �
B&P.C.far this reason _
�ate
� . � - . � Owner �
INSPECTOR'S NOTES
f • 1_ ��
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