The URL can be used to link to this page

Home My WebLink About1015A WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT � I hereby afEirm �hat� have a certificate of consent to salf � insuYe,or a c4rfifico�e of Workeri Compensation Insurance, HEATING • VENTILATING - AIR CONDITIONING or a certified<opy thereof(Sec.3800,Lob.E.J 76A364C CE-818(REV.10/81 J Policy No.�Compony Fa i rmnnt Tnc_ � ❑ Cartified wpy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY � Certified copy is filed wi�h the counry bwld�ng inspec-� FOR APPLICANT TO FILL IN BUIIDING fion depariment. (PRINT OR TYPE ONLV) ADDRESS Date 5��9�87 Applicant Rancho Air, Inc. ��A��T� Diamon B NO. TYPE OF APPLIANCE OR E�UIPMENT� . � FEE CERTIfICATE OF EXEMPTION FROM WORKERS' NEAREST � COMPENSATION WSlJR.4NCE . CRO55 ST. (Thi�sedion need not ba completed if the work involved by ABSORPTION UNIT,BTU DISTRICT NO. PROCESSEO BY fhe permiT ic for one hundrad dollars(;700)or�eat.) qIR HANDLING UNIT,CFM � �( I cerlify tha�in the performance of the wark for�which this r� �'d� permit is issuad,I shall not employ any person in any manner so as lo become sobject ro fhe Warkers'Compensofion laws. ��ER,BTU aecaovn�s or7e �Nsveaoa�s SioNnruae . 1 COMPRESSOR,6TU 27�AOO ZO OO ROUGH ApplicaN ICE TO APPLICANT: if, afier making this Cerlificate of VENTILATION Sv57EM FINAL � ('' Exemption, you should become subject to ihe Workers' � Compensation provisions of the Labor Code,you m�sl forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or fhis permit shall be � deemed revoked. 1 FURNACE� FAU�GRA'dNY.�_ 10 00 � UCENSED CONTRACTORS DECLARATION FLOOR eTU 00 I hereby affi�m fhot I am licensed under provisions oF Chapter 9 HEATER: SUSPENDED UNIT_ '(commencing with Sedion 7000)of Division 3 of the Business " WA�� ond Professions Code,and my license is in full force and effect. d 9 Re isters � 1.75 15 7 License Number �Q.S�� Lia Class �'—`�n � , ``-��C��'v p U Comractor R n�}11� nc.Dote�f15�fl7 �;o . s r� O ❑ I om axempt under Sec. � � �a-0 4'�:2`5 � y Plan check fe� � B.BP.C.fo.rhis reason PERMIT ISSUING FEE S 10 0 tl � y � ��" � Dare: TOTAL FEE !y( '2 U r.��`8 6 Signatore OWNER-BUILDER DECLARATION a�aN CNeCK naau[anli . I hereby affirm ihat I am exempt from the Contractor's License . . , J.aw for the following reason(Section 7031.5, Business and NAME � ( 'essions Gode): ADDRE55 LJ I, ps owner of the properfy, or my employees with � ❑ges as their sole compensafion,will do the work and C�T� . TEL.NO. ihe structu�e is not intended or offered for sale(Section � 70d4,B�siness and Piofessions Code). OWNER � ❑ I,as owner of ihe p�operty,om exdusively[ontrocting The Anden Grou with licensed cororacrors to consiruct the project(Seo- r"�A�� lo � � tion 7044,Business and Professions Coda). ADDRE55 CONSTRUCiION tENDING AGENCY CITY - TEL NO. I hereby affirm�ha1�here Is a consiruction lending ogency for C+OV1R8 967-9541 the performance of the work for which this permil is issued CON?RACTOR I , . (Sec.3097,Civ.C.). . � . . � AD�RE55 - � Lender's Name 1� � . CITY _ 1&nd TEL.NO. l�„4 �l . lender's Address SiATE LIC. I certify that I have read�his applimtion and state ihot the �,cer,se n,o. 380 h3 CwSS (,'—`2� - � above informalion is correct.I agree�o comply with all County ordinpnces and Siate laws relaling to 6uilding wnstruction, . � and hereby outhorize representatives af ihis County io enler , upon the above-mentianed properry for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ��S�.c�QC, !S 8 Signoture ot Applicant or Agen� Da�e � � � IN ECTORS OTES OWNER-EUILDER DEGLARATION� � � � � � � � �I heraby offirm�thot I om exempi from the Controciar's license Law for ihe following.reason (Setllon 7037.5, . � �� - - � ' � � "" � � �Business and Professions Codel:qny Ufy or counly which � . � � � � . requires opermit 10 construd,�aUer,fmprove,demolish, � � - . � � or repoir ony strudure, prior fo its issuanrn, also re- , - � �� . yuires fh2 t3pplitant lor such psrmit to file a signod stcte- � � � � ment that.he is licensed purwant to fh�provisions of the - . .._ , _ , , � . Con�racfor's license Caw(Chaptor 9(commencing w71h � Section 7000)of Division 3 of the Busrness and P�oles- � , sions Code)or that he is exempt}herefrom and IRe basis � , . , . . � � for Ihe alleged exemption. Any viofaHon of Sadion � � . . . . . � 703L5 by any applicanf for a permlt subjetts Yhe appli- � � � � � � cant lo c civif penoNy of not morc fhan live hundred " � -� � � ' . dolfors(S5C0).: .. .. . , .. , . ❑I,os owner of the property wiU do�he worJ�ond � , . , _ . , the struc�ure is not intended ar offered for sale. � �. � � � � - � (Sec.7044,BusinessandProfessionsCode: TheC�..rrao- � tor's Licenso!cw dces no�op�71y ic cn owner o(property who hulfds or improves fhereon, ond who does such � . - , work hlmself provided thol such improvamea�s oro nat � - Intendad or offered for s61e.If,howeve:,ihe buildinc�or � � . , improvement is sold w(th)n cne yecr of complalion,�be owner-build�r wlll have the burd�n olproving ihot he did , nof build or improve for fhe purpese of sale.) � � � ❑ I,w owner of the property,om exdusively con- � � - . tracting with!icensed contectors to constroct the project ' (Scc 7044J Business and Professions Code�The Conhar � for's License Cow does noi oppfy to on owner oi property - � wbo build;or improves thereo-n,ar,d who rontracts lor . . - � such projeds with a confracfor(sJ licensed pursuant la ihe Coniroctor's License Lavi;. � � I am exempt under Sec. B&P.C.for lhis reason ` _ . Date Owner INSPECTOR'S NQ7E5 � c'.. �s-•� `'t j=., .,�. :,,,w,., ;. .