HomeMy WebLinkAbout1014A WORKERS'COMPENSATIONDECIARATION � /y���ICATION FOR PERMIT �
I hereby af#irm that I have a cartificata of consant to self
insure,o�a carnficate ot Workers'Compensaron Insurance, �aA364c HEATING - VENTILATING - AIR CONDITIONING
or a cerufied copy thereof(Sec.3800,Lab.C.) �
CE-818(REV.10/81) '' �
PolicyNo.�Company Fa.irmnnt. Tn�.
❑ Certified copy is Mereby fumished. GOUNTY Of LOS ANGELES BUILDING AND SAFETY
Q Certified copy is filed with the co�nty 6uilding inspeo PQR APPLICANT TO FILL IN euuoiN�
tion departmant. � � (PRIM OR TYPE ONLV) . ADDRESS 1{
Date 5�29�87 Applitant Rancho Air,Inc. NO. TYPE OF APPIIANCE OR EQUIPMENT FEE ��CALITV Diamond Bar A TY' .
CERTIFICATE OF EXEMPTION FROM WORKERS � � NEAREST
COMPENSATION INSURANCE � CROSS Si.
, (Thfs section nead nOf be complotad Ii fho work Involvad by Ag$ORPTION UNIT,9TU OISTRICT NO. PROCESSED BV
tha parmB(c for one hvndred dallon(ZI00)or less.) AIR HAN�LING UNIT,CFM 0.�„
I cerfify fhat in the performance of Ihe work for which ihis � �O
permit is issued,I shall not employ�ony person in ony monner
so as to become subject to the Workers'Compensation Laws. BOILER,BTU APPROVAlS pAiE INSPECTOR'S SIGNATUFE ,
�"'� epplicant 1 COMPRESSOR,BTU ROUGH
- - ICE TO APPLICANT: If, after making this Certificate of VENTIIATION SvSiEM FINAL q
Ezemption, you should become wbject to the Workers'
Compensation provisions of fhe La6or Code,yoo must forih- EVAPORATIVE COOLER VALIDATION �
with tomply with such provisions or this permit sholl be �
deemed revoked. 1 FLOORCE: FAU��,GRAVH,I(�_. lo 00
LICENSED CONTRACTORS�ECIARATION � dt3
I hereby affirm that I am licensed under provisions of Chapter9 SUSPENDED uNli_
HEATER:�� wA��
'(commencing with Secrion 7000)af Division 3 of 1he Business �
and 7rofeuions Code,and my license is in full forte and effect. �
3$0543 i;�.cioss C-20 9 Re isters @ 1.75 1 v
License Number ��1 0 1,4 A
Cantroc�or R3riCh0 AlY',InC�a�e 8�1SIH7 , $, e � � p r a O
� V
I am ezempt under Sec. Plan chetk fee 1 0•G��rJ N
- B.&P.C.for tbis reason� pERM1T ISSUING PEE s e . �
Date: 10 0 e L:E,�L'S cs.�
Signarure TOTAL FEE L 8 2 0�8 6
OWNER-BUILDER�ECLARATION � PLAN CHECK APPLICAM � �
I hereby affirm that I am exempt from the Contractor's License . �
�w for the following reason(Sedion 7031.5, Business and NaME� . . .
, �essions Code):
IJ I, as owner o£ihe property, or my employees with A�DRESS �
wages as their sole compensation,will do the work and CI7Y TEL NO.
ihe struclure is not intended or offered�for sale(Section
� 7044,Business and Professions Code). - � - �
owNea The Anden Grou
❑ I,as ownei of the property,am exclusively mntracting
with licensad con}rodors to mnsiruct the projecf($ec- MAR � �
� tion 7044,Business and Professions Code). /oDRE55
CONSTRUCTION LENDING AGENCY C�TY � C Vlri& TEL NO. � I. �
I hereby affirm thot fhere is o tonstruction lending agency for 4 , �
the performance of�he work for which ihis permi�is issued CONTRACTOR
(Sec.3097,Civ.C.). . Ran h A' I .
' ' � ADDRE55 .
Lender's Name '
Lender's Address ��TY � U land � TE�.No, 81—�+801 � �
STATE LIC. .
I<ertify that I have read this applicafion and state thal ihe �ICENSE NO. CIASS . .
above information is correct.�agree to comply with all Counry
ordinances and State lows relating to building consiruction, .
� and hereby outhorize represen�atives of�his County�o enter � � .
�u on the above-mentioned property for inspecti n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
`Yt��.�OD_ ,
Signatura of Applicont or Agent �are . � � �
IN OR'S TEs OWNE�-GUILDER OECCARATION
� , i hareby�affirm iho�I om eaempt from the Controctor's
� � licensA Low for Ih= following reason (Senion 7031.5,
' � � � � � � � Business ond Profrssions CoaeJ:Any cityor county which
. � � ' . � � , requires o permil lo construd,olter,imprave,demofish,
� � .� or repclr cny sMucturc, prior to fts issucnce, also ro-
� � � quires ihs o�plicont for sucB permit to fi�e o signed stote-
- � mert!thot he is litensed pursuanf to fhe provlslons of the
- Confracfor's license Law(Cfiap>er 9(commencing with
� - - � Se<iron 7000)o(Division 3 cf ihe 6usiness ond Profes-
. sions Coda)or iha�hc Is excmplYhere(rom and fhe basis
� � for Ibe, vfleged e empfioa Any viofalian of Setlion
. ... .. � . . . 7031.5 by ony applicant�or a permif subjec�s the appl�-
- . � cant to a civlf penelTy oi nol mcre than five hundred
�,-� � , � � � . dallars[$50DJ.:
__ _ � � � � �� ❑I,os owner of the propAny wi11 do the worJLand
.� � , , . tfie structure is not iNended or offered for sala �
' � � (Sea 7044,Bvsiness cnd�Professions Code: 7ho C.....rcc-
� . for's[icense Law does not apply to en owner of p:operty
who builds or improves lhereon. and who does such
work himself provided ihot such improvem�nfs ore no�
� � - infende�cr cf#ered for sale.�If,hov�ever,!he building or
. , . improvsment is sold within one yeor o(complefian,fhe
� � oxmer-builda will hcva the 6urden oi proving fhot he did
� . not build or Improve for�he purpcse of sole.) �
- � - � � ❑I,cs owner of ihe prcperty,om exclusively con-
' � trocting witR licen.ed confractors�o construct thr_projed
� (Sec.7044)Business end Pro�essions Code:ihe Contror
. . �7cr's License Law does not eppfy}o on owner oi properry
- wfio builds or improves theresn,vnd wMo controtis lor
� _ . . � such projetfs with a confrattor(sf licensed pursuanf io
� - 1he Controcfor's licensc Lov�J.
� I am exempi under Sec.
. B&P.C.for ihis reason _
Dofe
. . . � � � � .� . � Owner
INSPECiOR'S NOTES
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