HomeMy WebLinkAbout0664A (4) WORKERS'COMPENSATION DECLARATION qppLICATION FOR PERMIT �6
I hereby affirm that I hove a certificate of consent to self
insure,or a certificate of Workers'Compensahon Insurance, 76A364C HEATING - VENiILATING - AIR CONDITIONING �S
or a cerrified wpy ihereof(Sec.3800,Lab C.1 CE-8�6(REV �OB1;
P❑ol�icy No. F 21926Compony Fairmont Ins.
Certified copy is hereby f�rnished COUNTY OF I.OS ANGELES BUILDING AND SAFETY
� Cerrified copy is filed wrth ihe coumy bwlding inspeo- FOR APPLICANT TO FILL IN euaoirv�
non deparfinent. ADDRE55 2�+202 E. Doeskin Pl. Lot
5/29/87 Rancho Air Inc. rPRuvTORrvveorv�n �ocaurv
Date Applicnnf �
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTIC -' . • "" NEAREST
COMPENSATION ' . CRO55 ST.
(This section need nof be completed if fhe work involved by AB$ORPTION UNIT,BTU DISTRICT NO PROCESSED BY
the permir is for ane hundred dollars(5700)or lexs.) q�R HANDLING UNIT,CFM
I certify ihat in ihe performance of ihe work tor whi<h this 1� ��
permit is issued,I shall not employ any person in ony manner
so as to become s�6jeU to the Workers'Compensahon Laws BOLLER.BTU nPvgovq�s �pie wS�ecTOa'SSiGNniuRe
�y2ste Applicant 1 COMPRESSOR,BTU 4��nnn l� QQ ROUGH �^t'l�rf�,
�iICE TO APPLICANT: ff, after making ihis Certificale of 2 vENTRATION SVS7EM oo FiNA! ,0 2
_.,emption, you should 6ecome sub�ecl to the Werkers'
Cornpensotion provisions af the Labor Code,yau mo5�forth- EVAPORATNE COOiER VALIDATION
with comply wdh s�ch provisions or th�s permit shall be
deemed revoked. FURNACE FAIJ_GRAV�7y
LICENSED CONTRAC70RS DECLARATION �- F�OOR eiU t5U�G6O— 1O OO
I hereby affirm�hat I am licensed under provisions of Chapter 9 SUSPEN�ED UM7_ -"�%b�.�A
(commencing with Secrion 7000)of Drvision 3 of the Business HEnTER WA��
and Professions Code,and my hcense is in full force and effeci. i;a o A x e 4 Q
i3 Re isters l. 22
License Nomber ��n54� Lia Class� , f 'O g v K�G J� V
�
Contractor P,fl.nrho a;�rgT�,.Date �'i/31/�7 - ' q'J�C J Z� �j
❑ I am exempt under Sec ('j,�i /'—Q,(� V
Plcn check fee d
B.8P.C.for thw reoson V1
PERMI7 ISSUING FEE$ 10 50 �
Date:
5gnature TOTAL PEE
OWNER-BUILDER DECLARATION PLAN CHECK AP7LICANi �
I hereby affirm tha?I am exempt from ihe CoMrpctor's License ,
Law for ihe following reason(Sechon 703L5, Business and NAME
�s`essions Code)�
� I, os owner of ihe property, or my employees w;ih ADDRESS
wages as iheir sole wmpensation,will do ihe work and
the sirucWre is not iNended or offered for sale(Section CiTY iEL NO
7044,Business and Professions Code?.
owhER The Anden Grou
❑ I,as owner of the proper�y,am exdusrvely cantrochng
wdh hcensed mnirac'ors to consirucf the pro�ect(Seo MAIL
hon 7044,Busmess and Professions Code) ADDRE55 -i
CONSTRUCTION LENDING AGENCY CITV TEL hl0 5 — �41
I hereby affvm that there is a mnstruchon lending agency for ,
the performance of the work for which this permit is issued cONTRACTCR
(Sec 3097,Civ C). A'r I
ADDRESS
Lender's Name
CITv TEL NO -_�
Lender's Address
I certify 7hat I have read this app6canon and sfote ihat ihe UCeNSE NO 3£305�+3 C A55 C-2�
above informalion is corre<� I agree to comply with all Counry
ordmances and Srate laws relating fo buildmg consirudion,
and hereby authorize represematrves of ihrs County to enier �
upo �abo�e-menti,on property f mspectio purp ses SEE REVERSE POR EXPLANATORY LANGUAGE
/� ��
Signal�re o<Appl�:onl or Ag�n��
{i
QP83FECZ��'��1@7ES C;WNEst—E�iJILUER t�EGLF.�2A710�i
he�oby cFtirm iLet I cm Fx3mpi from � ;,Contracio=s
� � � -- � _cer.=,e L �or rhe follow;ng racsen iS�dion 7C31 5
3us;r,ess c o'Fro;essicns Cad:�) Any c,iy or coun;y wn.cn
-- — ` � � � � reouires a parm�t;o;cr,shvci,ai(er.,m�rcv�,dcmofish
� � or rapa�r cny strucfore, ;>rwr to i, iss�anco, also r-
�� ' - quires tha cpp7iccr,i for such permit to fiJn c siyned stcto-
menf+ha!Be is firnnsao`pursucnl to 9ne prmision_of Yhe
Contrcctcrs;merse!cw;Cnapfar'J lcommenung;ii7n
Sect�on 70'JO)of Drr.sror 3 cf Irc 8usr;ess and Pro�es
sions Codej or ihat Fe is exernpf lherefrom cnd Ihe Sas�s
for rhe clleged e Ar,y violufior o/Section
— 7031.5 by any cp�l:��c�t for o�aermi!suojecfs'rhe app(�-
� cnnt ic a ivff penoiSy of not mare ihan frve hundred
, da!lacs i`�50^u)
❑�,cs ov.���. -"'- - , , . �.'I do the work,and
. . -- ---- --`— �ructure�s no' � �� �� fpr sa'�e; "
' ' � •' , �Ssc 7044,BusinEsscndYrofessionsCoda. iheCc .
� for's i�eanse Lcv✓does not c?p!y!o an own�r of proPcrly
w6n builds or imUrovas hhereon, cnd who dces suc
- `----� , ---�-"-- .rk h:mse!;previ:•'so'tha7 suc;:r.�provemer•,s are not
;�sended cr offared`or sale �f,he�vever,fho buif�?ing o�
�—- -- �m�nrcven;ent is soid wiihin one year c,`completia�i�tF.e
o�.vr.e:-buildzrwif;hcve fbe burde.^,of proving ihot he did
not build or impra�e iar 4hv�urpese o4 sale)
___ _ _ .�I,as ov✓ner d�hc prcport;�,cm exci�srvely co^-
' '�achng`:aitn licensed mn+rectors ro ccnsh�c•the prc�ec'
_________ 5cc .'04c;Susi��sss and Frolessrvns Coda The ConL-uc-
�or's Cicense to+,v daM no+epply 4o cn o•.vnar of p•operiy
__ � v�ho 6olfds or i:nprcves thereon,ar.d who contracts 4or
sucit pro;ec;s v�ifh a corPrac7cr(sj f;censed pursucnt to
_ :h�Coniraticr's License:mv).
am exempt unde.Sec. _ _
---- 8&P.C.for this reason -
Dcte----- — —
� Owner —_ �—_._-'--
IPISP£CTSTR'S I�1QYE5