HomeMy WebLinkAbout1006A (5)WORKERS' COMPENSATION DECLARATION
APPLICATION
FOR PERMIT
I hereby affirm that I have a certificate of consent to self
ICE TO APPLICANT: If, after making this Certificate of
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insurer, or a certificate of Workers' Compensation Insurance,
-•
76A364C _ - HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lob. C.) -
Policy No. F 21926 Company Fairmont Ins.
CE - 818 (REV. 107817 -- - - -
-
mplion, you should become subject to the Workers'
Certified copy is hereby furnished.
COUNTY OF LOS ANGELES
BUILDING AND SAFETY
Certified copy is filed with the county building inspec- -
FOR APPLICANT TO FILL IN
BUILDING I� 1�
lion department.
(PRINT OR TYPE ONLY)
ADDRESS 2440 E. Gold -point
Dale 5/29/87 Applicant_ Rancho Air,Inc.
deemed revoked.
LOCALITY
-
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
Diamond
CERTIFICATE OF EXEMPTION FROM WORKERS' -
hereby affirm that I am licensed under provisions of Chapter 9
NEAREST
COMPENSATION INSURANCE
ABSORPTION UNIT BTU
CROSS ST.
(This section need not be completed if the work Involved by DISTRICT NO. PROCESSED BY
the permit Is for one hundred dollars ($100) or less.) CFM
I certify that in the performance of the work for which this AIR HANDLING UNIT, 10 � Y
permit is issued, I shall not employ any person in any manner BOILERBTU
so as to become subject to the Workers , Compensation Laws. APPROVALS DATE INSPECTOR'S SIGNATURE
T Applicant -
1 COMPRESSOR, BTU
ROUGH
b
ICE TO APPLICANT: If, after making this Certificate of
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VM
VTIWTION SYSTEM
FINAL
mplion, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
EVAPORATIVE COOLER
VALIDATION
with comply with such provisions or this permit shall be
deemed revoked.
FURNACE: FAU XX GRAY
-
- LICENSED CONTRACTORS DECLARATION
1 FLOOR Btu
10 00
hereby affirm that I am licensed under provisions of Chapter 9
HEATER: SUSPENDED UNIT_-
' (commencing with Section 7000) of Division 3 of the Business
WALL
and Professions Code, and my license is in full force and effect.
- -
Registers @ 1.75
14 no
License Number 380543 Lie. Class C-20
— ,
Contractor Rancho Air,Incaa,e `8/15/87
❑ I am exempt under Sec.
-
Plan check fee
B.BP.C. for this reason -
PERMIT ISSUING FEE $
10 50
Date:
TOTAL FEE 1
44150
Signature
OWNER -BUILDER DECLARATION
PLAN CHECK APPLICANT
hereby affirm that I am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and
NAME
,
sessions Code):
>�=JJ I, as owner of the property, or my employees with
ADDRESS
wages as their sole compensation; will do the work and
the structure is not intended or offered for sale (Section
CITY TEL. NO.
7044, Business and Professions Code)..
- - --
--
❑ I, as owner of the property, am exclusively contracting
OWNER
The Anden Group
with licensed contractors to construct the project (Sec-
MAIL -
ADDRESS 1074 Parkview Drive
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
CITY' Covina - - TEL' NO. 6 —
41
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
''..
CONTRACTOR — -
RanChO'Air, In
- -
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
1232 W. 9th St.
CITY .TEL. NO.
Lender's Address
981-4801
- -
certify that I have read this application and slate that ,he.
LICENSE NO 380543 TE ctcass C-20
;21006A
tt••••o8
1••4450
••- •4450
0920-86
above information is correct. I agree to comply with all County - -
ordinances and Slate laws reloling to building construction,
and hereby authorize representatives of. this County to enter - - -
upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE_
Signature of Applicant cr Agent Date
I
10
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