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HomeMy WebLinkAbout0670A WORKERS'COMPENSATION�DECLARATION � � . . APPL'CATION �OR PERIY,IT � � � I hereby affi•rm that f�have o�cer�ificate of consent to self -� � . insure,or a certificate of Workers'Compensation Ins�ronce, �bA36ac HEATI:NG - VENTILATING - AIR CONDITIONING or a cerfified copy fhereof(Sec.3800,Lab.C.)� � CE-678(REV.10.�87) - � � � � � � - � � � - � ��yNo. F 21926 Company Fa�rmont Ins. CA�rff ed ropy is herehy t�,��ishAd. COUNTY OF LOS ANGELES BUILDING AND SAFETY �� Cerlifiep copy is filed with the counry building insper �FOR APPNICoANT ToOYFIL�IN� BUI�DING2� - 1 on de arrn,e+,f. aooeess 21}C E. Gin rT�o P �are 5�29�87 Applicont R2,riCY10 Air, Inc. LOCALT1"Diamond Bar CA Tract 4 . . NO. TYPE OF APPLIANCE OR EQUIPMEM1T � FEE . � � CERTIFICATE OF EXEMPTION�FROM�WORKERS . - . . . .... NEARE57 . � � COAAPENSATION WSURANCE�-� � � � � � �� CROSS si. � � (This sec}fon need not 6e completed ff�fhe work�involved by- ABSORP110N UNIT,BTU � - oisraicr No: �� ��' '� Peocesseo er ��the permit�is for one-hundred�dollcYs{5100)or�less.) qiR HANDtwG UNiT,CFM � ��� - � - i certify ihpt in the performance of the work for which ihis . r ('� �.� ��permif is�issued,I shall not employ any person in any mqnnar � - � . W � so as lo become sobjecYto the Workers'Compensation Laws., �BOILER,eiU� �� aaveov.cis oaie Wsaecroa•sSiGNnivaE � �'"°b ?.ppl canf ' �- COMPRESSOR,BTU ��A��� 1� �Q ROUGH � � �$ "��, � ICE TO APPLICANL lf, after making this�Certificate of .� VENTILATIONSYSTEM , .,12 -oo FINAL � q� . Exemption,�you sho�ld become sub�ect 10 ihe Workers' _ ._ . .__ . , . . . . Compensation provisions of tFe Labor Code,yoo must forth- EVAPORA7Ne COO�ER - V14L�DATION � with comply with such provisions or ihis permit shall be � - � _ deemed revoked. - . - � Fl1RNACE: FAU_GR�V,l7'y ' - � � LICENSED CONTRACTORS DECLARATION � � �- FLOOR B7U 6U+�— lO OO �� I hereby affirm ihat I pm licensed under prtivisions o4 Chapler 9 SUSPENDED "UNIT-�_ ,t�� HEATER: WALL �� � -.'(i 6�/,V A '(commencing�with Section 7000)of Di ision 3 of the Business � � and Professions Code,and my license is in full force and effect . �9 y.� �,� . 6 1 Re isters @ l. 22 ¢ � . . �-License Number 38�5�3 �Cc.C�ass.. . C-20 . . �. . , . V Iv9�O�.�LJr � �' Coniracfor .� .. .�ate � � � m,�V f.,,.��r� . :.� , ❑ I am ezempt under Sea . yd Plan check fee fj�,1 (�—g 5 y 8.8P.C.fo�rhis reaso� pERMIT ISSUING FEE$ 10 0 � Dafei 5yr,awre TOTAL FEE 65 2 OWNER-BUILDER DECLARATION � PLAN CHECK APPLICANT .. . . � I hereby affirm that I am exempt from the ConiraUor's License � . � � , . � for the following reason (Section 7031.5, Business and NAME � 'Fessions Code): . - . . . . . . . . �I I, as owner of ihe properfy, or my employees with ADDRESS . - wages as their sole compensarion,will do ihe work and � CiTY � ?EL.NO. . �� . ihe structure is not intended or offered for sale(Section - � 7044,Business and Professions�Code). . � �, owNeR The Anden Grou ❑ I,as owner of the property,am exdusively contrpcfing . . . _ . . . . . . . � wifh licensed coniracfors fo conshu<t ihe project(Sec- - Mq�� � � � . . tion 7044,Bvsines5 ond Professions Code). � ADDRE55 10 �+ Parkview Drive 201� . CONSTRUCTION LENDING AGENCY�� � � I hereby affirm thot ihere is a consiruction lending ogency for CITY COVlri2,� TEL NO, 6 — �:1 ► . � the performance of 1he w.ork for which this permif is iss�ed CONiRACTOR . R&11CY10 ES1Y' IY1C. (Sec 3097,Civ.C.). � � . � ' . . . .. _ .. . � . . .. . . . . . � � ' . ' ADDRE55 12 2 w. .th Sr,t. � . . . . . Lender's Name . _ � aTv U land rE;,No. 1-4 Ol Lender's Address �� � � I certif that I have read this a licatiort and�state thot the 57A7E - � LIC� � . y pp uceNse No. 0 �+ ciass C-20 above informotion is correcf.I agree fo romply with all County � � � ordinances and State Iaws�relating to.building construc�ion, - � � � - � � � ond hereby authorize representotives of.ihis Counry to enier � �. - , � � � -� � � �� � �- ��� � � � - upon th abbve-mentio prope.ry f 'nspec',n,p oses. SEE REVERSE FOR EXPlANA70RY LANGUAGE ��'�=��g�'_" ' �/� �'.� Siqna�ure o£Aopl'ican�or Ager�.t ate ' . - � , � � __. :1�� �7��'S P7� �S ` G9V+t"JER-E#U1l��R DEGLATts�IION _. .._.. . ..._ ._ .... . ..... . , ._.. . ....� ..., . , _,. . .. :. ...�.here6y ofFirm.that-i�am�.:exempP from Phe Conirdc!or's � .. . .. .- - ... ' -. �-'.:-. �.-..,'... . .... - . . . llcensa I.aw Eor�ihe�folidwing..reosor (Seciion 7�J3!i.5. � .._ ............... ... .. ._ , .. ...._. ... „ .. .. .,... ..,.. . ... . . . . .. . . ' ' 6usrr.ess ond Frofessions C'.ode;:Any ciiy or county which � � . . .��-'-.. ....-: �.:...'.. .. . .'. '..;equires a permi4 to�c6ristruct It..�;,'rmprove,.demolis6. ,�`-- � �� � '- ' �' � � � � ` ' - � '� � ' or repair„ony strutture,�priar fc ifs )ssuonco, also re- '' " �.- � �.. � - - - � - � � � � ; �-� •" �`qu[res fhe applicont for such permif to Tile qsigned gtafe- . � ��- . ' - - �� �� - � � � �� � � � '� � � �� � � menf that hejs lic�ns�d pursudn9 to 4he provis'rons af the �.. � � � "'--� � � ' � " � Ccntrcc9or's„Cicense Lcw(Cbapie��9�(camrrien<ing with `�' '�� ' � . _ �� � � ��-�` � ' � - � � � �� � � � � Se<tion 700GJ of Drv�sron 3 of the Susiness ar.d,Profes- �. � - � � �� _ ' � � i sions Code)or tha'he�s exem�f rherefrom nrt�d;he 8asi_a � �: . � , ' . .�._ . . . . .... .. ... � . lvr�ihe afle��d exempfion. Any vio)aiion of Sectian ' . � � ----" -� � � ' 7031.5 by cny pppl�cont.for o permit�subjecis ihe qppfi- . ._. ..._. _ .. . . . _ _ _. .. ��-." . .,, , _ . . ��� � � �cant ro n civil.penolty�of not more.than five hundred __. .�.-�... - . . . .. .. .�-- ...�:�. . . . . .'. �-.. .: . . . .. . _, .._ .. . . . � . , . . - dollars j5504).: � � �� - � � � . �❑I,oa owne�of the proparty vei��l do th¢worfi.t.pnd� , �_ . .. . . .._�. . . . . _ .. . .. �. . � �� . . " . � � - � �� ��-�. - � ;� . re is nof imended,or otfcred„ror sclo. ,� �. _ , ..:::, �.:'� . -_ ._. _ . .. .,.. . ...� � (S=t,'70i�3,Busiaess an�Professions Ceds Yhe C...;rac- _ _ .._____ .. .. � �.-�.. �: � � . . � ' � -`� dcr's Gcensc Law dqes�ot apply�to an owner of properPy � � �� . ����-- - �-who.bur(ds�or.imprgYes,:thereon, and who�oas soch � � ;�"- -- - work himsels`provided ihot such�improvements pre no� . _ .. ,,... . � � � . . - - . � .. _ � intended or o4fered for sa1e.If,huwever,tfie building or . . � . _. . . �� . .. . .� � �' ,. �improvement!s sala withirt.one_.year of comp(etlon,ihc , � � � - �- � � � � - owner-buiidzrwlilhavethe�burdeno{provingPfiaihodid , � , - � . . � _ - �'�nofbuifd or im;srove�for�iheporpose of sole.)- �� - �- . � . �� ��- - ' � `� �� � � ❑I,as owE�er o�}he projieriy,am exc us vely.con- . � . . � , . � , �� �tocting v✓itfi licensed cen!Padors-to construc`the projed � � . �. � -� ��`_ � (Sec.7044)6usinsss and Professions Gode:The Conirac- . . .._... . . -. � � tar'sticense idw does no4 cpply ta an owner of pro�erty , - � --- � -� � � � � . who builds or'improves;fhereon,.and wh�confracss.for , . � � . - � '� - � � � sutb projecfs wi3h a confractor(sj ticensed,pvrsuanf to - ' � � � ...... . . .. . .. . .. .. . � 7he Contrecior s License Law).. .' . . ."�... , . ... . . . . . . . � . .. .,... � I om.ex�mpt und�r 5ac:'_� -- - � . �� B&P.G.for this reason � ��_.�, : .�—�."" T � - — Date _ ,_: Owner : 17�SPECTOR'S t�f)TES