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Home My WebLink About1004A WORKERS'COMPENSATIONDECLARATION APPLICATIQN FOR PERMIT � I hereby affKm that I have a certificate of cansent to seff . insure,or a certificate of Workers'Compensation Insorance, HEATING • VENTILATING - AIR CONDITIONING or a certified copy thereof(Sec.3800,Lab.C.) ��`�� _ . . � . CE-818(REV.10/81) . P❑oNcy No.�2�2,Company Faj rmont. Tns_ � Certified copy is hereby fornished. - COUNTY OF L�S ANGELES BUILDING AND SAFETY � Certified copy is filed with ihe county building inspeo- � fOR APPLICANT TO FILL IN � BUILDING tion depariment. • (PRINT OR TYPE ONLY) � ADDRE55 480 Armitos Pl. Lot 2 Date 5/29/87 Applicont Rancho Air. Inc. IOCALITY Diam Bar A T 42 6 NO. TVPE OF APPLIANCE OR EQUIPMENT � FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION�NSURANCE . CRO55 5?. (Thls soetion nead nof be eompieted ff tho work involvad by AgSORPTION UNIT,BTU oisTeicT No. veocEsseo ev the parmif ta for one h�ndred dollaro(5100)or less.� qIR HANDIING UNIT,CFM {� . I certify that in the performance of the work for which this �� a` / permit is issued,I shall nol employ any person in any manner � gOILER,BTU so as to become subject to the Workers'Compensation Laws. nrvRovnts �ATE INSPECTOR'S SIGNATURE . 1 COMPRESSOR,BTU 27 s SOO ZO OO RDUGH � Applicant �JCE TO APPLICANT: If, after making this Certifimte of VENTILATION SYS7EM - FlnIA� q �Ezemption, you should become su6ject to the Workers' � Campensalion provisions of the labar Code,yOV mu5f{oriM- �qppRATNE COOLER . VALIDATION � with tomply wilh such provisions or Ihis permit shall be - , deemed revoked. FURNACE: FAU xX GR TY . iICENSED CONTRACTORS DECLARATION � 1 FLOOR� � eiu ��a�- lO OO I hereby affirm that I om licensed under provisions of Chapter 9 HEATER: SUSaENDED UNI7_ �(commencing with Section 7000}of Division 3 of the Business � WA�� . ond Professions Code,and my license is in foll force and effecC . } . Re isters e 1.7 lk 00 a � License Number 380543 Lic,Class C-2� � � =� a�.�l R V h s�s•a a oe Coniracfor Rancho Air.Incoare 8/15/87 � � � � � ❑ I om exempr under Sec. I.��•��{� � Plan check fee „ � „�(�(��'�� H B.BP.C.for rhis reason PERMIT ISSUING PEE s Z � Da}e: lO � GB.�b�86 TOTAL FEE, Signalure OWNER-BUIL�ER DECLARATION PLAN CHECK APPLICANT . I hereby affirm ihaf I am exempt from ihe Coniroctor's License . . , � Inw for the following reason(Section 7031.5, Business and NAME � � � �" essions Code): ADORESS IJ I, as owner of the property, or my employees wilh - wages as iheir sole compensation,will do the work and CITY TEt.NQ � � the strocrure is not intended or offered for sale�Sec�ion . 7044,Business and Professions Code). OWNER ❑ I,as owner of fhe properry,am exdusively coniracting �nden GrOU . . with licensed coMractors to conslrucf Ihe projeci(Sec- MAIL fion 7044,Business and Professions Code). - ADDRE55 - CONSTRUCTION LENDING AGENCY CI7Y . TEL NO. 6 - �L1 I hereby affirm that fhare is a mnsiruction lending agency for , ihe performance of the work for which ihis permit is issued CONFRACTOR Raneho�Air ZI1C. � (Sec.3097,Civ.C.). � . _ . � � , . ADDRESS � - � Lender's Nome CITY U 19.nd TE�.No. 981-1+801 � lender's Address . STATE LIC. I certify�hat I hove read this applicalion and sfale thoi the LICENSE NO. CLASS - � � above information is mrrecC I agree to comply with all CwNy � ordinonces and State laws raloting to building consiruction, . � . . ond hereby authorize represeMotives of this County to enter u on the a6ove-mentioned properry for inspedion purposes. SEE REVERSE fOR EXPLANATORY LANGUAGE . ��4f='-s_��L �i' �J Signalare of Applimnr or Agen� � IN ECTORSNOTES OWNER-EUILDE�DECLARATION ` ' � � . - I�hereSy offirm that I o aempi from the Conirocbr's � � License law for�ihe foliowing reason (Section 7031.5, � � � � � � � - Business and Professions Codei:Any city or munty which � � � requlres a pormii to construct,alteq Improve,demolish, .. � , � � or repair eny sfrucfvre, prlor fo its issuance, olso re- � � - � . �quires fhe cppl7cani for such perm7t to fi7e a signeal s4aTe- . . � � menf ffia!ha is licsnssd pursucnt�o fhe provisions o/fhe Coniracior's License iaw(Chopter 9(cvmmenting with � � � � Section 7CGOj of Division�3 01 ihe Business ond Profes- . sions Ccde)or fhat ho Is exempf iherefrom and�he 6asis , " � � � � � (or ihe vlleged exemption. Any violation o/ Secfion — .. . . � • . . 7031.5 by any applimnf for o permi�subjects Ihe appli- � � � � � � cani to a civil per;a!ry oi not more ihcn five hundred � �" - � � , dollars($500J.: � . . _ � �]I,as owro-of thr,property will do ihe work�and . ' � the structure is not imended or offered for sale. � � - - � (Sec.7044,6usiness and Professions Code: The C.,..�roc- . � � � � � . � for's Cicense Low does not apply fo pn owner cf properfy , � . who builds:or improves thereon, ond wfio does such � - � work himsef/provided Ihat such improvemenis ore not � - � ' infonded or offered for safe.If,howcver,the building or . - - Improvament is sofd x•iihin cne year of tomplrNon,ihe � � owner-6Wlder wlll have the 6urd�n of proving that he did � , . nol build or improve for tMe purpese of sade.) � � ❑I,as owner of ihe property,am exdusively mn- trocting v�ilh licensed contr�cters to censtruct the pro;ec� � (Sec.7044)Business and Prolessions Code:ihe CoMrco � - � tor's License!aw does not apply fo an owner of proper}y - - who bWlds or Improvcs lhereer„and who confroc}s for � . � � such projecis wlth a conlrottor(s)licensed pursuant m � �ihe Con}ractor's license Low). - � I am exompr under Sec. B&P.C.for ihis reason _ Date Ownsr tNSPECTOR'S NOTES � .�.�I t�' -. .� �. _-a ? .