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HomeMy WebLinkAbout1022A WORKERS'COMPENSATIONDECLARATION � APPLICATION FOR �PERMIT � I hereby a(firm that I have a certiiimte of consent to self � insvretior a•certiHcate of Workers'Compensa�ion Insorance, �bA�4� HEATING - VENTILATING - AIR CONDITIONING or a certified topy thereof(Sec.3800,lob.C.) - CE•eis(REv.10/et) � � - � - -� - � - � - I - P❑olity No. F 9l q?Fi Campany F i rmnrlt TnS. . Certifed copy�s hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY � Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN � BUitoiNG 1'� ' tion depar�meM. , (PRINT OR TYPE ONLYJ �+DDRE55'�µ� O GOZ O PI LOt 12 oa�e S/29/87 qpplimnr Rancho Air, Inc. iocAUT NO. TYPE OF APPIIANCE OR EOUIPMENT � � FEE �Diamond Bar CA Tract �2 CERTIFICATE OF EXEMPTION FROM WORKERS" NEAREST � � COMPENSATION INSURANCE CROSS ST. � • (This sactton naad not ba compl�t�d if fhe work involved by ABSOBPTION UNIT,BTU �ISiRICT NO. FROCESSED BV . tho permll is for oee hundrod dollcrs(f100)or Ia�i.J . � � ' I certify thol in Ihe performance of the work for which this A�R HANDLING UNIT,CFM �� �t permit is issued,I shal�not employ any person in any manner . °r so as fo become subjett lo the Workers'Compensation Laws. BOIIER,BTU nvoaovnii �ATE INSGEROR'S S�GNATURE ' 1 COMPRESSOR,BTU �6eDOO ZO OO ROUGH �p � D� applicant 'r 'CE TO APPIICANT: If, a4te� making ihis Certificale of VENTIIATION SYSTEM � FINAL '� � �.._�npiion, you should become subject to the Workers Compensation provisions of ihe Labor Code,you musf forlh- EVAPORATIVE COOLER �i V �� ATION � wilh comply wilh such provisions or fhis permil sholl be �� deemed revoked. FURNACE FnU._X.�GR iTv � � UCENSED CONTRACiORS DECLARATION 1 FLODR BTU I.O G7 . I here6y affi�m that I am licensed under provisions of Chapler 9 HEAiEk: WA�`NDEO UNIT_ � �', �� �2 2 A .'(commenting with Seclion 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effecl. - � -- � ' ' . �e } 11 Re isters � 1. 1 2 �+ " ' ° '8 O Litense Number 380543 u�.eio5s L''`2� " �A e 4 9,7 5 � eom.a�m� Rancho Air,Inc.�a,e $/15/87 . ► * � ❑ b. e�9,75� � I om exempt under Sec. w Plan check fee . D E[0-'8 6 y . B.BP.C.for ehis reason PERMIT ISSUING FEE$ z Date: 10 0 i Sgnature TOTAL FEE !y OWNER-BUILDER DEQARATION� PwN CHeCK avvuCnNi �. 1 hereby offirm tha�I am e.emp�fwm the Contractor's Licenre � ' Law for the following teason($ec�ion 7031.5, Business and NAME � � ' � - �"�essions Code): � �L I, as owner of the property, or my employees with ADDRE55 . , wages as their sole compensafion,will do the work and . ihe strutture(s nm tntended or offered for sale(Section CITY TEL.NO. , . 7044,Business and Professions Code}. . � ��. � OWNER ❑ I,os owner of the property,am exclusively tontracting � ', with licensed contrac�ors to construc�the project(Sec- '�'�� - -' ��, fion 7044,Business and Professions Code). ADDRESS 10 4 Parkviezr Drive��f201 CONSTRUCTION LENDING AGENCY ' CiTv- ' �-� -TEL.NO. 6 _ 41 . I hereby offirm fhat rhe�e is a construction landing agency for , . the performonce of the work(or which this permit is issoed cONTRACTOR � Y, I - (Sec.3097,Civ.C.). . . . - .. .- - - ADDfiE55 . � . . � ._ . . . . ' _ _ Lender's Name � . � . CITY . ._.TEL.NO. . —�y Ol - . . _. - . Lender's Address ' I cerlif Ihal I have read Ihis o limtion ond stdle Iho1 the STATE LIC. ' Y PP LICENSE NO. (y - CLA55 — O �- - -- � '- -' -- ... . . above iniormafion is correU.I agree to comply wi�h all Covnty ' . .. ardinances and Stote laws relaling lo bvilding consiruction, , � and hereby avihorize representatives of�his County�o enter - . � � "� "" �.� � � - � � -� - opan�he above-men�ioned pro eriy tor Ins ecnon urposes. SEE REVERSE FOR EXPIANATORY LANGUAGE '' S t� �g(sL _ __. _ . Signarure o/Applican�or Agent 'Dafe ' - - ' . . . �. . .... - -....� .. -... . . ..��. ., . u . � .. ' , . _ t.���. - ;:�� � .. , . . INSPECTOR'S NOTES OWNER-EUILDER DECIARqTION •� � -_.r; ,. . _ ,., � � _ • - I hereby�affirm tha�I am exempi.from 4he Comrodor's' ' ' ' '�' - '� - licensa law for the foilowing.recson (Sorfion 7031.5, . . _.__.._ ...__....__._._..._._.__ ...._. ...,._. ___. ..' _._. __. ._..._� . . ...__ _. ..._.. . ..__ . . - . "_"_."_ Business and Pro{esslons Cade)�Any UtY�r counfy whlch �� . � . . � � �requlros o pormif to conifrucf,aller,Improre.demalish, . ., "- -��--" " �- -- � - �- " -- � � ' � - ' � or repalr any strucfure, prior to Ifs Issuancc, olso rr � E __ _ _. _ .:_ ___.. _ . ._. . �. . . � . • _ . .4Wres fhoapplicanf/or suth permll fo lllc aslgnodsto�e- . " " - � '� - � ment Ifiat he 7s Iicensed pursuanf�0 1he provlslons oi fhe ' � i ' .....,........._. `.... ......"""_._"_ , ' � Contractor's itense Law Chaptnr�9(comm ncin wifh L ( e g }'������� ,,.. � , ��� ' � _ '� '� - �� Secllon TOOD)o(Divis�on 3 of ihe 8usiness ond Profes- � � � sions Code)or thal he is exempf lherefrom and fhe 6asis � " • � - ' � ..- -- -.-- '-'-�' �' � � ' „ , (or �he olleqed exemption.�Any violafion of�Seclion � �' � � 7031.5 by ony opplicpnt(or v perm��subjecis tbe eppll- .. ._.. .__._ '___. _.._.'.._1 __... ._ t_: __ _.. i, . . . , . , � , . . � � - -� ' ; canf fo a dy�l penolfy ol not�more than pve bundred ___.. ._'__ _...--_- . _. _ .. _ _ . �' doBan(5500J.: .. ' � � - � � ':„ _-_..�. ._ � � -- "� � � � � os owner of tho ropert will da ihe work,and G P Y , ., _ .. ' ._ _ ___._ _ _ . ' � � , � .�S.`„ � � , . , „ � "-Ihe strucWre is nol intended or.of(cred for spie. -'"� - - -- ' � - - -- ---- - -� —�- � � � � (Sec.7044,O�slness and Prolesslons Code: The� ;ao ' �'^' � ' ' � ror's License Law does no�apply 10 an owncr of proper�y � �� .�.+,t„�, � � . .:�_ . , - . . . _.__ _ ' ! who�builds or,lmproves Ihereon..and.who does.such , _- . � . . work himsell provlded fhof soch improvemeMs are no� ' � - - ��- � � infended'or offered!or svle.'If,,-6owevcr,.the buliding o� . � '� � improvement is sold wilhin one yeor of complef/on„Ihe . _.i .__�.-- � --- ownervbutldervnil hove ihe burden of proving tha�ho did � � , . � nof buifd or Improve for fhe purposn o(sale.)�' � : ! .� .., - ` . . - -- - � - - � ❑I,ps owner of the proper�y,om exclusively con- , � ' ' � ' , �-'� trc�cting wifh licensed confractors-to construU ihe project � �- - �� �- ��-- - ---- �� -- � ' (Sec.7044)Business and Prolessions Code:The Con�roc- � � , � � - --tor's licensc Law docs noi apply fo an ow.ncr of property '3--�- ----!-- � � - -�- - - � � ' who builds or improves}hcrcan,and who controcfs for � ,, � i � ' " � ���'��, svch projecfs wlth a confrocfor(s)licensed pursvont�o . ... ... . ._ _ . , . �� ' � � � � � - }he Conlrec}or's License Low). - . . . ... ..... . � f . � . . . . ... _ _ . . � ' � ' � ' I am eaempl under Sec. � � � - B&P.C.for this reason �� � � � � . . . , . . � . � �.____. �--- •------ - --�-----� ---� �- �. � . , Date � ' . . � � -� - .. � . . . .� . .. .. . .. ' . . .._ . .- -_ .- .`- --- � .. � � �� Owner � INSPECTOR'SNOTES -- --.-.- . ..._.-•' . .- �. : �� � � . ..� .. ' ---�-� - - . __ ...__. . . ._ �_ , . . . - - - �- � - -�� ..----- � -- -.... . . . • •i _o�s�l . � � �l'� � �_ 4. � 1� -� �,�.,.�Jo.., w..._� � �