HomeMy WebLinkAbout1169A WORKERS'COMPENSATIONDECIARATION � APP�,1CATION FOR PERMIT �
I hereby affkm that I hove a certi{itote of consenl to self
ins�re,or o cer�ificate of workers'Compensotion Ins�rance, 76A��� HEATING - VENTILATING - AIR CONDITIONING
or a certNied copy thereof(Sec.380p,Leb.C.) - CE-818�REV.10/81J � • � - - - �- -
P❑ollcyNo. Q�Company Fairmont � �
CertiF�ed copy is he.eby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed with the tounty bu�ld�ng inspec- FOR APPLICANT TO FILL IN BUIIDING
flon deporlmenl. �PRINT OR T'PE ONLY� ADORESS 1 Q 6 0 N. G o 1 d e n S r i n $ R d ,
Dale � ' �Applicant 1OC""TvDiamond Bar �
� NO. TYPE OF APPLIANCE OR E�UIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEnaEST
� COMPENSATION INSURANCE CRO55 5T. •
(This sacfion naad no}6o completad if fhe work Involved 6y ABSORPTION UNIT,BTU �151RI�f NO. VRpCE55E�BY
. tho permit is Tor one hundrad dollars(SI00)or lass.)
I[erfify Ihat in the performonce of 1he work for which this AIR HANDIING UNIT,CFM �D ����
permit i5 i55ued,I sholl not employ ony person in ony monner gOILER,BTU
so as to become subjett to tha Workers'Compensalion Laws. nvvaovnis DATE INSFECTOR'$SIGNATURE
Dale Oppiicanf 7 COMPRESSOR,BTU 30�000 � I OO ROUGH 7 �'� 8
NOTICE TO APPLICANT: If, after making this Certifim�e of vENTitATioN SYSTEM FINAL �
Exemption, you should become subjecl to the Workers'
Compensation provisions of�he Lobor Code,yoo must for�h• ¢vnvOennve coOtee ' VALIDATION
wiih comply with such provisions or this permit sholl be
deemed revoked. FURNACE: � FAU_GRAVITY " . �
� LICENSED CONTRACTORS DECLARATION itOOR - BTU �
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPEN�ED UNIT_ �
HEATER: WA��
'(commencing wi�h Section 7000)of Division 3 of the Business , }
and Professions Code,and my litense is in full force and effecf. - - - - � 0.
litenseNomber 380543 liaClass C��� � U
co�r,o«o, Rancho Air Da�e 8-31-83 � �> > �9A o
�
❑ I am exempt under Sec. , �' � ' '�'8 w -
Plan check fee �
� 8.8P.C.for ihis reason' •� •3 2�2 5 Z
Do�e: PERMIT ISSUING FEE S 5� . .3 2 3 2 5 c=>
S�gnature � TOTAL FEE 3'L .'Z�'j
� OWNER-BUIIDER DECLARATION PIAN CHECK APPIICANT O�.Z�l�$Ll �
I here6y offirm tha�I om e.emp�irom�he Controc�or's license �
Law for the following reason(SeUion 7031.5,Business ond NAME -
Proiessions Code):
❑ I, az owner of Ihe properfy, or my employees with A�DRESS
wages as their sole compensatian,wili do Ihe work ond
� 1he struct�re is not intended or offered(or sale(Seclion �Itt TEL.NO.
7044,Business ond Professions Code). - �
OWNER TNE ANDEN GROUP
❑ I,as owner of the property,om ezclusively confrocting � ,
with licensed contractors fo conshuct the prajetl(Sec-� �rA�� - � ' _
Iion 70G4,Business ond Prafessions Code�. A�DRESS 6 2 9 -C o v i n a B�V d.
CONSTRUCTIONLENDINGAGENCY � Cirr $dfl �1md5, CA �T���"�� 599=6864
I hereby affirm that there is a construction lending ogency for ► •
the performance of Ihe work for wh�ch ihis permit is iss�ed CONiRnC70R R a n e h o A 1 I n c. '
_ (Sec.3097.Civ.C.�. � . . � . . . - .
� AODRESS 158 ard ccess Rd. #D - � � � -
Lender's Name
c'TM U ldnd, CA TE�.."o. gg1-4801 - �
lender's Address -
STATE UC.
I tertify that 1 have read this applim��on and s1a�e that the UCENSE NO. CLASS . .- . . _. . .
above iniormotion is correct.I ag�ee to comply wi�h all County �
' o ces and Slale laws reloting_10 building construcflon, _ ,
and h y auihorize representatives of this County ro enter � - � - � � � " - '- "- �
u on he bove•meniianed property fo�inspeciion pur oses. SEE REVERSE FOR EXPLANATORY IANGUAGE
_ ��.
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