HomeMy WebLinkAbout1171A WORKFRS'COMPENSATIONDECLARATION APP�,'CATION rOR PERMIT �
I herehy affkm ihat I have a certificate of consent lo self
ins�re,or a certificale oF Workers'camPe�So��o„o,,,,,o��e, ,�436ac " - � � HEATING - VENTILATING - AIR CONDITIONING
or a certiiied copy thereaf(Sec.3800,Lab.C.) CE-BIB(REV.10/81) � �
��y No.F 04329com a� Fa i rmont
CernRed copy is herebyf urnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy ts filed with the coun�y building inspeo- FOR APPLICANT TO FILL IN- BUi�DiN�
fion department. . ADDRES$ 1040 N
�PRINT OR TYPE ONIY)
oe�0 aPPu�a�� • LOCAL1TV Diamond Bar
NO. NPE OF A7PLIANCE OR EQUIPMENT FEE
CERIIFICATE OF EXEMPTION FROM WORKERS' NEnaE57
COMPENSATION INSURANCE CRO55 ST.
ABSORPTION UNIT,BTU
(This sacflon nsed not be complafad iF Ihe work tnvelved by DISiRICI NO. PRp�E55ED 9Y
fhe parmit lf for one hundred dollars(SI00)or la�s.) AIR HANDLING UNIT,CFM ./ ���
I[ertify fhot in the performance of ihe work for which ihis � D
permit is iss�ed,I sholl nof employ any person in any manner BOILER,BTU
sa as to become subjecl�o the Workers'Compensotion Laws. _ avveovnis T[ INSPFROR' IGNpTURE
PO1e ePp���o�� 7 COMPRESSOR,BTU 70 ROUGH �3 (
NOTICE TO APPIICANT: Ii, ofter moking this Gertifica�e of ZO VENTILATIONSVSTEM 80 0o F�NA� 3 a
. Exemption, yov should betome subjett fo the Warkers'
Compensation provisions of the Lobor Code,you must forih• EVAPORnTIVE COO�ER � VALIDATION �
ith complj. wirh svch provisions or Ihis peimif shall be
deemed revoked. FuaNace: Fau_caavitt
LICENSED CONTRACTORS DECLARATION ] Fi00R BTV .
I here6y affirm that I am licensed under provisions of Chapfer 9 HEAtER: SUSPENDED UNIt_ �
�(commencing wi�h Setlion 7000)of Division 3 of the Business ' '�'//�� '
ond Professions Code,and my litense is in full Porce and effett.- � � }
a
LicenseNumber- �g�F4� lic.Class r-7� • ► 0 ,
V
ConrracrorRancho Air oo�e 8-31-83 `�
�117.tA o
❑ I om exempi under Sea �� ���� �8 W
Plan check fee
B.BP.C.for rhis reason� � y
Da�e: PERMIT ISSUING FEE S ],Q 5 Q I •3 2 3 2 5 Z
Signature �
TOTALFEE 23 25 ••32325� ^
' OWNER-BUILDER DECLARATION RAN CHECK APPLICANT O�,c 4-S 4
I hereby affirm lhaf I am ezempt from ihe Cantractor's license , �
Law for ihe following reason(Seclion 7031.5,Business and N.4nnE �
Professions Code�: -
❑ I, as ownei of the property, or my employees with AD�RE55
wages as their sole compensofion,will do the work ond ��TY tEL.NO.
�he structure is na�In�ended or offe�ed for sale(SeUion � �
" 7044,Bustness and Professions Code). � -
o`""ER .THE AN�EN GROUp
❑ I,as owner oi Ihe propery,am ezclusively contracling
with licensed conlradors 10 tonslrud the projetl(Seo- r"�A�� `� � �
' �tion 7044,Business and Professions Code). � nooRE55 629 C0 V 1►1 B 1 vd. .
CONSTRUCTION LENDING AGENCY CRY - TEL NO.
I hereby affirm that there is a conslruction lending agency fo� S d n 11TId S CA 5 9 9�-6 8 64
the performante of ihe work for which Ihis permit is issued CONTRA�'fOR Rancho al I nc � �
(Sec.3097,Civ.C.1• _ ..... . . . '
ADDRESSl 5 H . � � � ��
lendei s Nome
lender'sAddress arv �pland, CA TE��"�981-4801 - - - � - _- . . .
STATE UC.
I certiFy tho�I have read this applim�ion and stote tho�rhe uceNser,o.380543 CLASS C-2� . - - -
above i rmation is correct.I agree to comply wiih all CouNy �-� ` ' �
or ' a ces and$tate laws relating to building canslruction, .
and re y au�horize represenlatives oI ihis County lo enler . �� �' �- � "- �- -� � - �
on r e�bove-mentioned property(o�inspection purp ses. SEE REVERSE FOR EXPLANATORY LANGUAGF .
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