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Home My WebLink About0469A (4)WORKERS' COMPENSATION DECLARATION APPLICATION v �j FOR PERMIT I hereby offifm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, HEATING -VENTILATING -AIR CONDITIONING or a certified copy thereof (Sec. 3800, Lab, C.) .. 7eA3eec Policy No. wrs�F�s 1L Company d Ins TJn4 CE -BIB (REV. ID/81) hereby Certified copy is hereby furnished. furnished, COUNTY OF LOS ANGELES -- BUILDING AND SAFETY X❑ ,Certified copy is filed with the county building inspeo - department. FOR APPLICANT TO FILL IN BUILDING ADDRESS 639 S. Foxhaven Place - tion (PRINT OR TYPE ONLY) 5-29-88 RANCHO AIR INC. Dale Applicant LOCALITY Diamond Bar CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST ' COMPENSATION INSURANCE CROSS ST. t 6 (This •°c11on nerd not be completed If the work Involved by ABSORPTION UNIT, BTU' Di$LRiCI N0. PROQS D BY the permit Is for one hundred dollars (=IDB) or less,) I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM D permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE ,F,^l Applicant - ]- COMPRESSOR, BTU 1 00 ROUGH ICE TO APPLICANT: If, .after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' —. Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER 'VALIDATION with comply with such provisions or this permit shall be deemed revoked. FURNACE: r FAU_G AVITY LICENSED CONTRACTORS DECLARATION 1 FLOOR B7UW nor) 00 I hereby affirm that I am licensed under provisions of Chapter 9SUSPENDED HEATER: UNIT_ '(commencing with Section 7000) of Division 3 of the Business WALL and Professions Code, and my license is in full force and effect. } CL - License Number 180S0 Lic, Class C-0O �2 0 4 6. 9 A V - - - - Contractor RANCHO ATR, TNmote 8-41-87 ' ' ° °' ° �.,� 8 K O - ❑ I am exempt under Sec._ I • • ,4 6 2 5 m Plan check fee n- B.BP.C. for this reason - • • • 4 6 2 5 Z Date: PERMIT ISSUING FEE $ 10 50 0 Signoture TOTAL FEE 46_.25 OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License j* for the following reason (Section 7031.5, Business and NAME ( bssions Code): - - I._J 1, as owner of the property, or my employees with ADDRESS wages as their sole compensation; will do the work and _ CITY TEL. NO. the structure is not intended or offered for sale (Section 7044, Business and Professions Code). ❑ owner " OWNER THE ANDEN GROUP I, as of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAILADDRESS 1074 Parkview Drive #1201 - tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY" TEL. NO. 967-9541 I hereby affirm that there is a construction lending agency for na - the performonce of the work for which this permit is issued CONTRACTOR - - - ► (Sec. 3097, Civ. C.). TNC - ..- - - ADDRESS 1232 W. 9th Street Lender's Name Lender's Address CITY U land - TEL. NO. 981-9541 - - - I I certify that 1 have read this application and state that the TATE I SCENSE NO. - CLASS - above information is correct, I agree to comply wish all County - ordinances and Stale laws relating 10 building construction, - - - and hereby authorize representatives of this County to. enter - - - - -- - - " up the above- ntioned property for inspecti n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signarure of AppI� nt or Agent Dole -- - "- - INSPECTOR'S NOTES OWNER -BUILDER DECLARATION ,�-,..;-, ;.. s - . -. - , .. ,._, ,. - ` -- .'I -hereby offirm'thol I am exempt.from'1he Controdor's ,,,.; License Law for the following reason (Section 7031.5, • "' Business andProfessions Code): Any city or coupty wfilch 'requires p'permit to construct, alter, improve, demolish, • - _ - --- - -- - '- - -' or repatr structure, prior to its Issuance, also re- ' ,any qv res tha oppficanf for such permit to file a �signod stafe- ment that he !s licensed pursuant to the provisions of the Contractor's: License 'Low (Chapter 9 (commencing with - ' Section.7000) of Division 3 of the Business and Profos- iions'Code) or that he is exempt therefrom orrd the basis ' - - -- for the alleged exemption.'Any-violation of Section .....7031;'$ by,anY applicant for a permit subjects the appll- •r. cant to a civil 'penalty of not more, than five hundred dollars ($500).: t .__ .. _._.�" .''- : _' !_:-- . _ .._ - -:_. '_ .,:.%. - .'. ❑ I, as owner of the property will do the wr-yand 1 thest, ct isnetintended or offered for sales " - - - -- '• - - - - - -- - -- -' f r , e and (Se 0nd Professions Code: The Canirao •, ' ' -, , „- - tor's License Low does not apply to an owner of property _.'i: _' _'_' - ,_ _ .. .. :.-__._ _ _ _.._. _. ..._ - •i who builds. or, improves thereon, and .who does such work himself provided that such improvements are not -(:' - '... . -. - intended or' offered for safe. If, however,' the building or -- _. improvement Is sold within one year of completion, the _• .- - -' _ ,- owner -Wider will have the burden of proving that he did not build or improve for the purpose of sale.) - _ - -- -• • - -----' '' " ,. .. ❑ I, as owner of theproperty, am exclusively con- - - - iracring with licensed contractors to construct the project 7044) Business and Professions CodeThe Confroc- _(Sec. ' `- - tors License Low does not apply to an owner of property ' -"-"- --- - -- -- - - --- - - - - - - - - who builds or Improves thereon, end who contracts for _ - such projects with a contractor(s) licensed pursuant to " - - - - the Contractor's License Low).' I am exempt under Sec, - B & P.C. for this reason Date ,.', ... .. ..Owner INSPECTOR'S NOTES `'