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HomeMy WebLinkAbout1006A '� WORKERS•�aMPENSAT�oNOE«ARAT�aN ,� APPLICATION FOR PERMIT � � I hereby affirm Ihat I have a certificate o(consen�to self , . . iniute,-or a cerfificale of Workers'Compe�saron Insurance, �bA�d�_ - . HEATING - VENTILATING - AIR CONDITIONING or a certified copy rhereof(Sec.3800,Lob.C.) - cE-8�8(Rev.t0/e�) � -�- - � - �- � � P❑olity No. F 219`26 Company Fairmont Ins. � � � - . ' Cerrfied copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ' ��CertiFied copy iz filed wirh the county building inspeo � FOR APPLICANi TO FILL IN � � BUiIOWG I�1� � iiondeparlment. (PRINTORTYPEONLY) NDDRE552440 �'.'. ('TOZC� O1T1't P ./Lot 22 oa+e 5/29/A7 qppi;ca„�_Rancho Air,Inc. �ov+uTYD• NO. TYPE OF APPl1ANCE OR EQUIPMENT FEE � CERTIFICATE OF EXEMPTION FROM WORKERS - Ne.4ee5i � COMPENSATION INSURANCE � CROSS ST. (Thls s�ctfon nud nof be complatod if tha work fnvalved by ABSORPTION UNIT,BTU � oisreicr No. raOC[SSED ev tfl�p��mif I!Fof on!flundrod do��afs(s100�o��esf.� � qIR HANDLING UNIT,CFM ' I certify ihof in the performance of the work for which this �V �Y permit is issued,I shall not employ any person in any monner BOILER,BTU so as lo become sobjed fo tha Wo�kers'Compensaiion Laws. . � nPraovnts onTe INSGECT04'S SIGNATURE i oppliconl � � ]_ COMPRESSOR,B7U ROUGH b � ' �ICE TO APPLICANT:'If, after making this Certificolo of vENTIWTIONSY57EM FlNAt � mption, you should become subject lo the Worked . _ _ Compensarion provisions of ihe Lobor Code,you muSt forth- EVAPORATIVE COOIER • VALIDATION with comply wirh such provisions or this permit shall be deemed revoked. � �� FURNACE: -Fnu XX GRAV - � � LICENSED�CONTRACTORSDECLARATION� 1 FIOOR stu ZO OO . � � I hereby offirm thot I am Iccensed under provisions of Chapter 9 5U5aeNOE� � " UNiT_ � �- � � � � '(commencing with Section 7000)of Division 3 of the BuS�nesS HEAiER: ��A�� . and Profession5 Code,and my licensa is in foll iorco and effecL � � � � - - �' Re isters l. a License Number 380543 �ic Closs C-20 - , �1 0 0.b A V Rancho Air,Inc `8/15/87 � tt• • • • °8 O Contractor pote . � V I am ezempt under Sea � •e Q Q,rj Q u� � Plan check fee n. B.BP.C.for ihis reoson - �'+ •4 Q J��� 2 PERMIT ISSUING FEE S 10 0 oare: Signa�ure TOTAL FEE �y(} 0�.2 0�'8 6 � OWNER-BUILDER DECLARATION , MnN CHECK a.PPUCAnIT � I hereby affirm that I am exempt from ihe Conlracror's License , . lnw for ihe following reoson(SeUion 703i�.5, Business ond NnME � � � - � t�J°essions Code): � �J I, as owner of the property, or my employees wilh ADDRE55 woges as iheir sole compensation;will do the work and � -- _ . the siructure is not intended or offered{or sale(Section Cltt TEL.NO. . � 7044,Business ond Professions Code).. .� , - � � - -- � -- own,ez The Anden Grou � ❑ I,os owner of the propeny,am exclusively conrracting . with licensed wNraUors lo mnstrucl�he project(Seo- �"�� 1' �- ' � � � lion 7044,Business and Professions Code). ADDRE55 ]_� µ D" . � CONSTRUCTION 1EN01NG AGENCY ��TY�� Covina � - �� - �TEi."o.� 6 4i � I hereby offirm ihal Ihere is a tonstruclion lending agency for — ' the performance of the work for which ihis permit is issued � � COMRACtOR � � — � ---� � ' � (Sec.3097,e��.c.>. . Rancho��Air In . � . .. . . .. . . ..._ .. _ _. . � . ADDRE55 � .. .. ..__ . . _ - -.. _ . .' � . . . � Lender's Name � CI7Y .TEL.NO, lender's Address � — -� - � �- � - � I certif rhat I have reod this a licotion and smre�hol+he. srare - � uc. � Y PP LKENSE NO. 3SO5li3 � � CLASS- C-2O.. '__ __ . . . _.._ ..._ _ _ . ... above informolion is correU.I ogrea ro comply with oll County . � . � � ordinonces and$late laws relaling to building construction, . and hereby au�horiza represen�atives of.this County�o enter � �� � �-" ���� � � � � � -� � � - - � ' , uaon the obove-mentioned property for ins ection purposes. � � $EE REVERSE FOR EXPLANATORY LANGUAGE_ �� ��+�T, � ��_ . � • . _ . . � . ..._ _ . . . . 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