HomeMy WebLinkAbout1170A WORKERS•�oMPENSAT�oNOE«ARAT�oN APPLICATION FOR PERMIT � . �
I hereby affhm that I have a cer�ificote of consent to self
insure,or a certificaie of Workers'Compensolion Insuronce, 76A�64C HEATING - VENTILATING - AIR CONDITIONING
or a cerli(ied copy thereof(Set.3800,Lab.C.) �E-eIB(REV.10/81) � - � �
O�yNo.F� 04329comPa�Y Fai rmont
Certitied copy is hereby furnished. COUNTY OF LOS ANGELE$ BUILDING AND SAFETY
� Certified copy is filed wiih rhe county building inspec FOR APPLICANT TO FILL IN sunoirvG
tion deparfinent. (PRINT OR TY.PE ONLY) nooaess 10 50 N. G
Date Applicont ����TM Dl ffl d
NO. TYPE OF APPLIANCE OR EOUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' � � NEnaEST
COMPENSATION INSURANCE CROSS ST.
(Thl�sec}lon noad not be complefed IF 1he work involved by ABSORP�ION UNIT,BTU p15iRICT NO. PROCESSFD BY
tha permH fs for one h�ndred do�lars(3100)or lass.) 'O �
AIR HANDLING UNIT,CFM
I tertify�hat In the performance of the work for which this - . �
permit is issued,I shall not employ any person in any monner gOIIER,BTU
so os to betome su6jec�to iha Workers'Compensa�ivn Laws.. nvvaovnts Art iNsv� R'S SIGNATURE
�ate Applitant ] COMPRESSOR,BTU �O OO ROUGH � �
NOTICE TO APPLICANT: If, after moking �his Certificate of 20 vENTitATION5Y5TEM $O oo FiNA� b v'� 02-
Exemption, yov should become subject ro �he Worke�s' _
Compensa�ion provis�ons of the la6or Code,yo�mvs�forlh- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be � �
deemedre�oked. � FURNACE: FAV_ VI .
LICENSED CONTRACTORS DECIARATION � � Fi00R B7U �O OO
I hereby otfirm that 1 am licensed under provisions of Chapter 9 HEqtER: SUSVENDED UNIT_ �
'(commencing with Section 70D0)of Division 3 of�he Business �'A« }
end Professians Code,and my license is in full Forte and eFfect. 5 3 e i s t � .7 5 �
LicenseNumber 3Rf1543 lit.Ciass (�—�n— , V
OC
co�,,a�,o,Rancho Ai r Dare8-31=83 �
� �117.OA v
I am exempt�nder Sec. d
Plan check fee ' $�• • • • •8 �n
B.BP.C.for this reoson PERMIT ISSUING FEE S ].O rjO I'�3 2.�2 Jr �
Daie: TOTAL FEE 323 25
5gnature •;e 3 2 3 2 5 c�
O�NNER-BWLDER DECLARATION� PIAN CHECK APPLICANT �
1 hereby affirm that I am exempt from the Contractor's license'' � 0.��2 4`8 4
low for Ihe following reoson(Secfion 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the property, or my employees with
AD�RESS
� wages as their sole compensaiion,will do the work and� ��tt TEL.NO.
the slr�cture is not inlended or o(fered for sale(Section
7044,Business and Professions Code�. � OWNER �
❑ I,as owner of Ihe property,am ezclusively contracting �TH E N D E N G Q U P
with licensed tonvactors fo tonstruct the projed(Set- N'p'�� .
�ion 7044,Business and Professions Code). - ADDRE55
CONSTRUCTION IENDING AGENCY � CiTY TE�.�NO �
I here6y at(irm�hal Ihe�e is a tonstruction lending agency�or S d� �1 Rld S C A . 59 9—6864 �
ihe performonce of the work ior whith this permit is issued �pNTRaCfOR Rancho Ai r, I I1C. � -� ,
(Sec 3097,Civ.C.). . � , �
AooRess.1586 Noward Access Rd. #D
Lender'sName ��TYUpland� CA 981-4801 - � - - � -
7EL.NO.
lender i Address
STATE L�C.
I terlify�ha�I have read this applim�ion and slate thot the uc�Nse r,o.380543 � cuss C�2� � - � - -- - — � - -
a6ov 'nformaiion is correct.I ogree to comply with all County .
or es and State laws relating lo building tonslruction, _ �
and �by authorize represemafives of this County�o en�er � � . �
- u o t above-meroioned properry for inspecuon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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