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HomeMy WebLinkAbout1007A WORKERS'COMPENSATIONOECLARATION APPLICATION FOR PERMIT I hereby afflrm lhaf 1 hove u certiiicote oi consent to self _ insare,`or o certificale of Workers'Compensalion i�s��a��e, .�aA�4C. . � � .. �HEATING-- YENTILATING - AIR CONDITIONING � or o ce�tified copy thereof(Sec.3800,Lab.C.) . � . � CE.BIB(REV.10/BI) ' �. �.�� .. . . ; - . Ocyt�o. F 2192E>�omPany Fairmont Ins. Certifled copy is hereby furnished. COUNTY OF LOS ANGELE$ BUILDING AND SAFETY O Certified copy is filed with the coonry building inspec• FOR APPLICANT TO FILL IN ' eunoiNo fion deparlmen�. . ADDRESS �� - (GRINT OR TYPE ONLY) oore 5�29�87 aPPu�aor Rancho Air, Inc. LOCAL1TY Diamond Bar CA Tract NO. TYPE OF APpUANCE OR EOUIDMENT � FEE � CERTIFICATE OF EXEMMION FROM WORKERS' NEnREST � � COMPENSATION INSURANCE CROS55T. ' � (This sacilon naad no}ba compl�tod if tha work inrolvad by ABSORPTION UNIT,BTU OISfRICi NO. PROCESSED BY lhv parmli la(or ona hundred dollars(3100)or lass.) q�R HANDLING UNIT,CFM y 1 certify thm in the performance of the work for which this f Q . C(„ � permit is issoed,I sholl not employ any person in any manner gOiIER,BtU � so as fo become svbjetl to the Workers'Compensa�ion lawsr . nvvxovais DATE INS�ECTOR'S SIGNAiURE - 1 COMPRESSOR,BTU 27.SDO SO OO ROUGN �� . � '�L,� � � ' p� opplicom . r 910E TO APPUCANT: If, aher making this Certificme of VENiILATIONSYSTEM � ' FINAL �. � . �Exemption, you should become subject �o the Workers' Compensation provisions of the Labor Code,you musi forth- EVA70RATIVE COOLER . � VALIDATION � with comply with such provisions or this permi�sholl be ' � _ deemed revokecJ. � � FURNACE: FAU Xx GRA ITY ' , LICENSED CONTRACiORS DECLARATION � FIOOR BTU Q , . �I here6y offirm Ihat I am licensed vnder provistons of Chapler 9 HEATER: SUSPENDED UNI7_ � � , '(mmmencing wilh Se�tion 7000)of Oivision 3 of the Business � S"/A« �. • . ' and Professions Code,and my license is in(ull force and effect. - -- � �- '. ' - � � �"' 8 Re isters @ 1. ' 14 00 �1 0 0 7'A a License Number ��OS�-F'3 Lit.Class C-2� . � � �o • • �� �'y " � '. Contractor RIlIIC�'10 Air,IriC.Dote S�1SIS7 - � � O � _ i= •aa.so � 1 om exempl under Sec. W Plan check fee < . <4 G,5 0� n' 6.8P.C.for this ieason' � � y PERMIT ISSUING FEE S � oa�e: 10 0 • 0�20�&6 5gnarure T07AL fEE �yjy OWNER-BUILDER�ECLARATION PLAN CHECK AVPLICAN7 '. � � I hereby affirm Ihat I om exempt from Ihe CoMroctor'S License , - . �l w for the following reason(Seclion 7031.5,Business and NAME � �� � °essions Code): � - �- , , U I, os owner of the property, or my employees with ADDRESS � � - wages as iheir sole compensotion,will do fhe work ond � � � - the structure is nal intended or offered for sole(Section CITY TEI,NO. , 7044,Business and Professions Cade). � � � � OWNER The Anden Crou � ' ❑ I,os owner of the property,am exdusively coMrptling - . ' with licensed contraclors to constroct the project(Sec- - ��� �� �� - � -� � � - I. . � � tion 7044,Business and Professions CodeJ. �1DDRE55 , . CONSTRUCTION LENDING AGENCY CITY '. " � - TEL NO,' 6�— �1' I hereby affirm Ihol Ihere is a construtiion lending oqency(or , � ihe performance of the work for which fhis permit is issued �pNTRACTOR �RB.RCYlO Air �Ine.- �-' �-� ' (Sec 3097,Civ.C.). - - . . _-. ADDRESS . ... . . . . .. _ . ,. � . .. ._. .. �. .. . . . Lender's Name � aTr U land rei.No. 81-1i801 Lender's Address - �� � -� �� � I certif that I have read Ihis a licotion ond state Ihot ihe STATE - UC. ' � '� Y PP LI[ENSE NO. .CLASS' _ . . __ . . . . _. : . . .. .. . ..... . a6ove informetian is correcl.I agree to comply wilh all County ordinances and State laws rela�in9 to boilding consiruUion, � � ' and hereby authorize represeniotives of lhis Counfy fo enter � � � � , �- � �-� � - '�, � " � �- -" � � " �on I�ve-mentioned roperty for In pectio purposes. , �SEE REVERSE FOR EXPLANATORY LANGUAGE ., . . .��, _. . . . . . '. �� ` Signal�re of Applimnt or Aqent Da�e . . . . .... .�.... . .-.- . . .. . . - _ - p ; . -_ , . , �,,,, ,, ,, ,,, ,;,, ,, . _. .. . '• � ' ' " - •• IF�SI'ECTOR'SNOTES ' OWNER-EUILDERDECIAFFATiON.�. , ...... ........ . . ....�,; ._....... ,,.�. . ,. . . � � I hereby affirm that I am excmpt from the ConlroUor's ' � ""'" � """�' �"'"' License Law for'�the followin�,reason (SecHon,7031.5. _ "'"....._. ......._ ._'_. {_.w_.�._' _. . .__ .....__...,.' _ '....... . _. __. �-..:. ... .. " .;'._. ._._. ..__... .__ "' slness and i'ro(essions Code):Any clry ar munry whfch Bu � . ,, �� � - � ' requires a perml(to conslruct,alter,lmprove,.demofish, '�� -�-- �-�-. ...-��-'-- �:','.... ..-_.'.��' - - --� �:. . ''�' . �� i � or repair any sfrudure. pt7or to!fs Iswance, olso re- 1 � :�-�� '� . �� � i. '� '��" `= i � . �� � �_.. __quiresiheappiicahtforsochpermNlo0lodsignedatafe- y_.—__ _.., __.�_.' . - . . �-. .. .. , . . , .. . __.. .._ - �__ .....__... _. . . , . � . • ment lfiat he Js licensedpursuanf fo the provls7ons of thc ' � � • , Confrodor's Clcense Lavi(Chopfe�9(commencing w/t6 • .__. .._...._ " � t.-'..`..".-. ";.. :: ...". ..,'.. . ".. ',. � . __.._... _____ ___ .. . . - ' , ,, Secfion 7000)of DiWsion 3 ot fhe Business and Proles- . . ', , � , ' � sions Code)o�that he Is cxempt therefrom ond the b,asis � . '.� , , � r�, � �: :. .__..._. _ ____..... , " �, �� for�fhe clleged exempfion: Any violafion o(�Sectlon . __'�,r-. . . . � 7031.5 by any applfcanf for a permH subjecfs Jhe appfl- . . :- � --- ----- �--.. _--� � �� , - , � � , - , � - . . . � ' i _ .--..-.-. .-- - -. - .. � .•..., cent to a civll n y f hundred �pc olt� o not more'fhcn 11vc �_- --_-_ ---._ -—. - -_- -._..... __._..� � dollars(S500J.: , . �� .. . . . .. ; � , �I . . i. ..''. ' ' �� .... .____ _. _.:_ ..__._.�'. .� ,�. � ❑I,o.owncr of Ihc rop^rl will do ihc work.and .t_` � . . . . . . _ . _. _._ . � -_ . . � � � �,�.��., -�-� � , � , . . ,�_th�e strudure is not iNended or offered for solc ��'^` ;` --.., ._.� ,.� . , , � . � . �� .. . t -- . - -- �- � �- �- �-- -- - � � � � ,.,(Sec 7044,BuzinessandPro/essfonsCod �7heC_,.rac �` t^�.�. �i .;:c',�,- ', - . � . .. . .. - -ior's Ltcense law does not upply lo an owner of properry _. .._.__. : � • �� :� � � _. ,__ ___' _ ..__ _ _ _ _,, _ _ � who builds or.improves fhcr¢on,�and who doos such � � , - ..... .... work himseH provided�hof such lmprovemenfs�are nof ' � ' � -�- �� ' '.'� ��- �� - -- - � . � lnfendedbr of(cred lor sole,ff,howwer;Ihe bullding or ,._ ... . .. . .. .. � � __._. ._. ._ _..� � , � �� �improvement ls sold wl}filn one ycor of complelion,fhe � � � --� - -- -� - -- -- ' ��� ownervbu1lderw1lfhovotheburdenolprovingfhathodid � .__. � _ . _ .. .._. .. __ .., _ . � , . , . , , . �� �not build or improve for Ihe purpose o�sole.)�' . � ' � ' . �.- �� ... . . ,.� -�-- �� - ❑I,as owner of the propory,am e.dosively con- �. . � - � � � -����-�reciing with licensed contrattors�to-corishoct the project � . �- �- -- --- ---�- �---— -- - � . �Sec.7044)Buslness ond Professions Code:The Conlroc� � � � , � -� tar's License!vw-docs nof opply fo on owner ol property � � - �- -� � � --- � -- - � - - - - who bvllds or 7mproves�thereon,and who contrdcts for i , �' . . . . ; ' .� � . ., wch profeds with a rontrocfor(s)licensed pursuanf ro . �._ . .. . ... -.. .. . ... . - ..... . . the Con4rec}er's L7cense Caw).' ' � . . . - . . . � ' . � --. .. I am exampt undet Sec.� .. .. . . - � � � 8&P.C.for ihis reason� � ^._ , . . - . . . . , .. � , � . . .._._.._._ ._- �--._..._..--- --- --� _ _-- ------. . . � .. . . Dale � . .. . . � . ' --._ ._.._ .. _. ..� .._ ..� . ..._, . ..� . .. . � � � j .. , . . .� . .- . �... . .��,. ..� .':.. __. . _ _ _ _ . ... . _ Owner � -- _ . . ._. -- • . _ _. � INSPECTOR'S NOTES � � ' �� . . � � ----�-- --- ____. . ._ .� _ . .. �.. ... . _ ` . . , . . -- - } . .- --- .__... _.__. . ._._ �.� .,... , .,. .,,._ . .. ., . .� , , . . . .�. � . . . ... , . ,. . � • t�`��-:.�,,r��_ _`�,f��� .G�.!2..,..t}.�'1/