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HomeMy WebLinkAbout1012A (5) / ' �7 WORKERS'COMPENSATIONDECLARATION A�PLICATION FOR PERMIT I' I hereby offnm tha�I have a cerlilicale of consent lo seH ' . insure,`or a cer�iiimte of Workers'Compensation Ineurance, j6A3taC HEATING - VENTILATING - AIR CONDITIONING GS or a certified copy tbereof(Se�.3800,lab.C.) _ _ . � , CE•818�REV,f0/BIJ � � , � - -—�— � a�y Ne. F Z�.92E�ompany Fairmont Ins. � � � CertiFled copy is hereby fumished. COUNTY OF LOS ANGELES . BUILDING AND SAfETY � Certffied copy Is filed with the wonty building inspeo- FOR APPLICANT TO FILL IN � sU�lowG �" � `~ . tion depanmenL . (PRINT OR TYPE ONIY) . ADDRESS QI�(yZ �',. (�..OZCZ oint Pl. L Dote 5/29/87 Applicant Rancho Air, Inc.. : �ou�m � . NO. NPE OF APPLIANCE OR EQUiPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' � NEAREST • COMPENSATION INSURANCE CRO55 ST. (Thfs sactlan naad not be complotod iF the work Invoivvd by ABSORttiON UNiT,BTU DISIRICT NO. iROCESSED BY fhe permlt Is for one hundrad dollars(SI00)or lefs.� ' q�R HAN�LING UNIT,CFM � � I certify that in the performance of the work for whi<h this 1� (�',� permit is issued,I shall�ot employ any person in ony monner gOILER,BTU so as ro become subjett to the Workeri COmPenSafiOn LOWS. AGVROVALS� DATE INSPECTOR'SSIGNAIUFE - � . 1 COMPRESSOR,8TU `�-7��DO ZO OO ROUGH � � ��� ppliconf ICE TO APPLICANT: If, after makin9 �his Certifimte of VENTILATION SVS7EM . FINAL �` Exemplion, yoo should become wbject to the Workeri , � Compensotion provisions of�he Labor Code,you must(orlh- EVADORATIVECOOLER VALIDATION- � with mmply with such provisions or this permit sholl be deemed revoked. . . FURNACE � FAU�_GRAV - ' � � LICENSED CONTRACTORS DECLARATION 1 i�OOR BTu lO OO I here6y affirm fhat l am licensed under provisions of Chapler 9 HEATER: SUSPENDEO � UNIT__ '(commencing with Secfion 700D)of�ivisian 3 of the Business K'A« and Pro(essions Code,and my license is in full force and effecf. � . �" Licente Num6er 380543 Lic.Class C-2� 1 �1 01.2 A V Contractor RunCho Air,Inc.oa+e 8/15/87 — , �� • • • �g � ❑ I am ezempt under Sea �4 �4 b 2 5 tVii B.&P.C.for this reason� � Plan che[k fee' . . � � • s �(J.�'�v c=a t�i� PERMiT ISSUING FEE S 10 0 z Dare: Oft20�86 Signature TOTAL FEE !j( '2 � � OWNER-BUIIDER DECIARATION rlaN CHECK avrucaNr '� I hereby afiirm�hat I am exemp�from the ControUor's License , . � for the following reoson(Section 7031.5, Business and NAME `essions Code): � ' . - L.1 I, os owner ot the property, or my employees with ADDRESS � � � wages as iheir sole compensation,will do ihe work and . the structure is not intended or offered for sale(Section Crtv � TE�.NO. � , 7044,Business and Professions Code). � �� � �� � � � OWNER. . ❑ I,ai owner of the propeny,am eaclusively contracfing MA` . wilh licensed contracbrs to cons«utt the projecl(Seo- � qDDRE55 l� �1 V� w Dr 201 ' � � tion 7�44,�Business and Professions Code). CONSTRUCTION LENDING AGENCY -- �iTy - ' � - TEI:'NO. � - . I hereby affirm�hat ihere is a construUion lending agency for � — , � ihe performance of the work for which this permit is issued GOMRACTOR � � � -� �� ' � � -���- � (Sec.3097,G�.c.�.� � Rancho Air Inc. ' . . _ . _ .. _ . .. . . . ADDRE55 "� 12 `Z W. t�l S't. . .... �, . . . ..., . . . ' _ . ._ . .. Lender's Nome nrv U land rei.No. 1-4 Ol , lender's Address � � � I certif that I hove reod this a lico�ion and ato�e that the .. STA7E LiC. �, � Y PP LICENSE NO. LL ... _.. CLA55 C�2O .. . -. - . ...-.. .... . . above information is correct I agree to mmply with all County � . . . . ordinances ond Stote laws relating to building construction,, � . _ . ond hereby outhoriae representatives of this County to enler � � � - � - - - ' �� ' ` ���� �. �� ��- - - � -- � - u on ihe obove-mentioned property for in ection purposes. � SEE REVERSE FOR EXPLANATORY LANGUAGE � C�k�l S� � i s cp Signalure of APPliront or Agenl Oa�e . . . . . - . . . . . .. . . �. .. .. . ' , ,, . . . < ,.. . . . . . ,. . . . . _ .. „ , ` ` • • ' - • IN1rECTOR'S NOTES � OWNER-EUILDER DECLAIFATION"; ' � � I-haro6y atfirm ihal 1 om exempt from Ihc Gonlractor's "' " ^�� " ' "���'�-- Licenso Law for ihe�following reoson{Sertlort 7031.5, _'_.�.� .._._._' . '_._. __.__......._.. ....____...__. . �` � '- �"'--""" '" -�" ' ",' """ . � ,. .. �"'-�'--'"--�-' 6osinessondF�olesslonsCodeJ:AnydtyorcouNywhich � � �- � � . �: � ' � �_,,� : � � � ' � ��requlres o-permll ro conslrucf:al�er,fmprovc,demallsh, I �..._. _ . ,. ._. _ ....__:�-_._ '.. ' __ .. , , .��,.,. .��_ .. .. repolr an�sf c.�p�or - � o� rucfur t �l�s lzsuance, olso re " . - . ' � � . qutro fhe op licanf for s permif lo f!!e o slgno(1 stole- __....__.'_._ _�:' _ _.__..'_..:_. ._ _.:_._. _ :. '. :..' ,�,� . . . . . . . � menf 1Fa�hels licensedpursvon�to ffie provlslons o/�he � � - � � . � Confrcctori.Ucense Law�(Chopfor,9(commencing wifb ,..____�.._.._..._ _,._.�__-.._.._._..__-"_"........._'..... , �. ,-� -: � .Sectian 7000)p(Division 3 0l th�e Qus(ness and Prafes� .- __ ..,'.- 5- . ,__ �'- -� � ....� . . ... ..�.. ._ . sions�Cby any applfcon�lor mP�fhcrelrom�and Ifie basls � odeJ or that he Is'exc , I � � � � 1or Ihe afle d exem flon. Any violcfion'of Secflon I._._.__.__ ._ _ � .. ' � . � 703L5� ,aper�ni�subfeclslhe.aPP��' �� . .. . .. . . .. . . ..,._ . _ � � cant.io.a dvif penalty of�nof more than/ivo,hundred . . .. ... . _ . , .. . ., �- -- .._----��-�--�--- ---._ ---- �-�--'-�- -- - - dollors(5500).� . . �� � � . ��� .. .� :�- '� -�. ...- .... --,�r. . � � ❑I,as owner of the pwperty will do�he wor4 and " '� '� �.:,'., ' , � ., .� - . � , . � _ ;'� the slructure is not intended or�oifered for salc.-�'�. -.`= ': '� ..�'�� ' .��..' � .`.-- -"--. -_ � .. . �� �. .. .. . (Sec.7044,Bus(ness andProfessions Code: �7fieC_..rac- . � ._ . ... . . . ... , .. '" ��'�''� � '' � � .�, ..for's L(censelow does not cpply to on owncr al properly . , ,.,:...:,-..: . , � . � --� - -��� ' � � ; ' c,'� . who builds or Jmproves thereon, and who does such � . �, ,. . _,. . . . , work 61msellprovided Ihot such lmprovemenls are nol - -- � � � inlended or'o(fvred Iarsale.�If,however,}he buifding or � �' , _. .� .. . _ .. . � � ��� improvemenf 7s sold wlihln one yeor of complefion,��}hc � �� � ---�-� r-- - �.��- '.`:_._ .. _J . ' ' owner�bvllderwillhvvefheb�rdeno(provlrtgthothodid . � . . � �, , • , � not 6uifd or tmprove for fhe purpose o!eole.J � � ' �--�-- --�� � -� ' � - ' ' ' � , ❑I,as owner of the property,om exduslvely con- . . � �, , -"�� IraUine��viith licen�ed mntroctois to construU Ifie project � � - -- -- �-- - -� - � (Sec.7044)Euslness and,Professions Code:The Conkac- � � , . . . . : -�- -lor's Liccnsc law dors-no}apply to an awnc��ol property .' " � -� - � � � -'---� - ----- - - - --� �-� -��-� -- who 6uilds or Improves fherean,ond who contracfs for - - � . � � �� � - ��� -� ,� sucA projecfs wilh a coNracror(s)licensed.pursvan�fo �. __ . _ .. . . __ . _.__ .-. . _ � - � - ---tbr Confractor's Lfcensc Low).�' ' ' ' � .. _.._. __ . . _ . .. . . . __ __._. . __ . . _. .. ._. ... . � � - � � �� � I am exempi�nder Sec.' ,- � � B&P.C.for�fhis reason .� .,. �� ' ��"`�.� -- -.__ .__ ..._.__ _.___._- ------ --_ .__ � � . . � . - Date � �. . ' � .. _ _ __- -- - - -.__.. . . , , .. . � . . ... � ,. .. � '.i�;. . � . ,. � . �. .. �- _ __ ' _ . _ Owner INSPEG70R'S NOTES - - • . ,.;.., ., , .. ., ... , _-, ,. _ _�:�,1���,�� �..�� � � �^�� �_ _.,�._ ��:�.. ,�: