HomeMy WebLinkAbout1168A WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PERMIT �
I hereby affhm Ihat I have a certifico�e of consenl lo self
insure,or a cerlificale of Workers'Compensation Insoranca, 76A764c -- - . HEATING --VENTILATING - AIR CONDITIONING
or a cerfified copy thereof(Sec.3600,Lab.C.) CE•B18(REV.10/91) - � � - - - '
P❑olfcyNo.F 04329Company Fairmon . �
Certified copy is hereby f�rnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed with the caunty 6uilding Inspeo FOR APPLICANT TO FILL IN BU��DiNG
fi0n flepOr�mErll. (PRINT OR TVPE ONLY) ADDRE55 1�7� N. G o 1 d e n S r i n s R d
Da�e Applicont L0C11Npiamond Bar
NO. TYff OF AP7LIANCE OR E�UIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS si.
(This�ettlon nsed no1 bv complatod if fhe work involved 6y ABSORPTiON UNIi,BTU DISIRi�i ry0. _ YROCESSEU BY
Ihe permi}is tor one hondrad dollars(SI00)or less.) q�R HANDLING UNIT,CFM
I cerlify lhat in ihe performance oF the work for which this �Q ����
permit is issued,I shvll not employ ony person in ony monner
so es lo become s�bjett to Ihe Workeri Compensotion lows. BOIIER,BTU AFCROVAIS D TE INSGEf R'S S�GNA7VRE
Date Applicanf 7 COMPRESSOR,BTU 7 OO ROUGH 'f /y 8 �
NOTICE TO APPIICANT: If, after making ihis Certifica�e of 20 VENTILATIONSYSTEM $ oo FiNal �
Exemption, you should become subject lo ihe Workers'
Compensolion provisions of Ihe Lobor Code,you must fOrlh- EVAPORATIVF COOLER VALIDATION
with comply with such provisions or this permit sholl be
deemed revoked. � FURNACE: � FAU__ RAVITY �
� IICENSED CONTRACTORS DECLARATION ] FLOOR � BTU 7 O O �
I hereby affi�m thot I am licensed under provisions of Chap�er 9 SU57ENDED UNIT- � " '
'(commencing with Sec�ion 7000)of Division 3 of the Business HEATER: WA�� .
ond Professions Code,ond my litense is in full force and effed. - - � - �"
a.
Ucense Number 380543 tia Closs C-20 - , V
a
CoNroclor��ncha n11' Dote�$-31-HS - - � �
❑ I om e*empt�onde�Sec.' `� � �8 A w
a.aP.C.for�h�s reoson Plan check fee . �� � � � �a N
oote: PERMIT ISSUING FEE S 1 50 I •3 2'J�2 5 ?
Si natore TOTAL FEE _
9 •.•32325�
. OWNER-6UILDER DECLARATION PIAN CHECK APRiGANT �
I hereby affirm thal I am e.empt from the Contractor's litense . � 0�,��l°'8�l
Law fo�the following reoson�Sedion 7031.5, Business and N.4nnE �
Professions Code): �
❑ I, os owner of fhe property, or my employees with ADDRESS
woges as rheir sole compensaticn,will do Ihe werk and
tfie structure is nat intended or affered(or sale(Section CITY TEL.rv0. �
7044,Business and Pro(essions Code). - � .
OWNER THE ANp�N �GROUP �
❑ I,as owner of ihe propeny,am ezdusively contrac�ing MA l
wilh li[ensed conlra[lo�s lo canslruct Ihe project(Sec- qDORE55 6 2 9 C 0 V 1 n d B� d.
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CiN ' TEL.N �
I hereby afiirm that theie is a construc�ion lending agency for -
the performonce of the work!or which ihis permlt is issued - �pNTRACrOrz -- � � � -
(Sec.3097,Civ,C.). . . . . ' ' 1
, ADDkE551586 Howard Access Rd. #Q � �
lender's Name �
aTrU ldnd, CA rEi."o.ggl-4801 -
Lendei s Address -� � ��""
I certif that I have read this a licalion ond stote�hat tha . S7n7E LIC. .
y pp uceNseNo.380543 . ewssC-20 . -- . - . . . . _ . _ . .
above information is correcl.I agree to comply with oll County .
ordin c s and Sla�e laws relalinq�o'building canstructivn, ,
on reby aoihorize repiesentati�es of fhis Caun�y to enter � � - - - " ' � - �
��e qbove-memioned �rinspectio urp es. SEE REVERSE FOR EXPLANATORY LANGUAGE _
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