HomeMy WebLinkAbout1018A (9) WORKERS•�oMPENSAT�oNOE«ARAT�oN� . APPLICATION FOR PERMIT �
I here6y affirm thal I have a certificate of consent to self
�nsure,or a certificore of Workeri Compensation�nsurance, . �bA3a4c HEATING - VENTILATING - AIR CONDITIONING
or a certi(ied topy ihereof(Sec.3800,La6.C.) �, �
� CE-B18{REV.t0i81) � - - - � -- -�
v❑ol�'cy No.F 21926 compo�y Fai rmnnt Tn�_
Ce�tiRed topy is here6y furnished. COUNTY OF LOS ANGELES. . BUILDING AND SAFETY
� Certified copy is filed with the coumy building inspec- FOR APPLICANT TO FILL IN eunoirrG
tion deportment.- � (PRINT OR TYPE ONLY) ADDRE55 Q �
Da+e 5�29��7 Applicanf—R£?.1'1(`}lt� Air� Tnr, �aA��TYDl3]ROIICI B
NO. TYPE OF APPLIANCE OR EOUIPMENT FEE
CERTIFICATE OF E%EMPTION FROM WORKERS' NEnRE57
COMPENSATION iNSURANCE CROSS ST. ,
(Tbts saNion nesd noT be complalad if fha work Involved by Ae50RPT10N UNIT,BTU D6rcic�rvo. rrto[[SSFo Br
fhs permit I+for ona hundred dollars(s100)or less.� qIR HAN�LING UNIT,CFM
I certify ihot in the performance of ihe work for which this � � ��i
permit is issued,I shall not employ any person in ony monner
so as to become wbjeU to the Workers'Compensolion Laws. bOILER,BTU AVPROVAlS DAiE INSPECTOR'S SIGNATVQE
^—e applicant " . �- COMPRESSOR,BTU �6���� ]_Q �Q ROUGH � �/ )
�ICE TO APPIICANT: If, atter makinq Ihis Certificale af VENnLATION SYSTEM F�NA� /0 �
Exempiion, you should become subjec� to the Workers'
Compensotion provisions of Ihe Lobor Code,yo�must forlh- EVAPORATIVE COOLER V LIDATION
with comply with such p�ovisions or ihis permit sholl 6e �
deemed revoked. FURNACE: FAU___X.iGRA
� LICENSED CONTRACTORS DECLARATION � �- FLOOR BTU �ZD OO
I hereby affirm that I om licensed under provisions of Chopte�9 SuSaENDED UNIT_ .
HEATER: . WA��
'(commencing wiih Section 7000)of Division 3 af the Business r T �� 8 A a
ond Protessions Code,and my license is in full force and effect.
11 Re isters L� 1. V
License Number �a�S�l� Lia Closs r.-�n . . , $�. . a . •a a
Cororac+or_RariChO Air,Inc nare f�/l 5/R7 I • •4 9.7 5 p
❑ I om exempt under Sec. � s� •4.9,7 5 c=i w
Plan check fee y
B.BP.C.for this reason o�.2�•�8(�
PERMIT ISSUING FEE S �
Date:
Signature TOTAL FEE 1}
OWNER-BUILDER DECLARATION PtAN CHECK nPPLICANT .
I hereby offirm that I om eKempt fram Ihe Controctor's Litense �
tnw for�he following reason(Seclion 7031.5,Business and NAME '
`J�ssions Code):
C:1 I, os owner o(the property, or my employees with AD�RE55
wages as their sole compensalion,will do Ihe wDrk and
the structure is not inlended or offered for sole($ection tltt TEI.NO.
7044,Busine:s and Proiessions Code).
- OWNER The Anden Grou
❑ I,as owner of the property,em azclusively contracting �`
with licensed contraclors�o[ons�ruct the project(Sec- qDDRE55 107k Parkview Drive �2��.
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY ��TY COVlIIa TEL.NO. _ 4 � �
I hereby aHirm thot there is a tonstrvction lending ogency for ,
the perfamance of the work for which ihis permi�is issoed CONitiACiOR Rancho l�lY' Inc-. �� �
(Sec.3097.Civ.C.). . .. . .. .. .
ADDRESS 1•2 •� �., .th � � . -
. Lender's Name �
� CITY U ...TFLNO. _ _. . . .
Lender i Address — �
I certif that I have read this a litation and state iha�the STATE UC.
y pp UCENSE NO. LG CLASS - _ - �- -. -- .. , ..
above informa�ion is correct.I ag�ee to comply wiih oll Counry .
ordinances and Stote laws reloting 10 building constroc�ion, -
and hereby auihorize representatives of Ihis Covnty to eNer , -- � � �'� �- . " " - " '
�u on the abave-memioned property for insp tnon p rposes. SEE REVERSE FOR EXPLANATORY IANGUAGE
z,-P- � 5....c.�lL2o e� r S , __
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