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HomeMy WebLinkAbout1009A WORKERS'COMPENSATION�ECLARATION � � , /yPPLICATION I�OR PERMIT � . I hereby affirm that I have a certificate of consen�to self � instne,wr a cerrficate of Worken'Compensaiion Insu�once, 76A364C ,-.HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof(Sec.3600,Lab.C.J -CE-eie(Rev.l0iai) - - -� - " P�olity No.�Company Fairmont Ins. � � Certilied copy is hereby f�rnished. COUNTY OF LO$ANGELES BUILDING AND SAFETY � Certified copy is filed with the county building inspeo FOR APPLICANT TO FILL IN BwIDiNG � ' fion deParlmenl. ADDRE55 2(�Ij 6 E. GOld Oillt Pl LOt 1 - � (PRINT OR TYPE ONLV) Dofe 5�29�A7 APPi;�a„r Rancho Air, Inc. i°°°uTYDiamond Bar CA Tract 42 NO. TYPE OF AGPIIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST � COMPENSATION INSURANCE � ' ' CRO55 ST. '� - (This saction nead not ba complvlvd I(1hv work�involvad 6y ABSORPTION UNIT,BTU DISiRiCT NO. . vRp�E55ED B� fhe permit fs for one hundred dollars(5100)or less.) qIR HANOLING UNIT,CFM � � I certify Ihat in the performance of the work for which this ��� �� � permit is issued,I shall not employ any person in any manner BOILER.BTU so as to become s�bject to the Warkers'Compensaiion laws. avraovnts DATE INSCEROR'S$IGNATURE Applimnt 1 COMPRESSOR,BTU 27�SOO ]_O O ROUGH �,�� �ICE TO APPLICANT: If, afrer making this Certificale Of VENTIIATION SYSTEM � FINAL . �6.rmption, you should become subjeu to the Workers' � Compensation provisions of the Labor Code,you musl forth• EVAPORATIVE COOLER VA�� ATION with comply wilh such provisions or this permit shalf be � deemed revoked. FURNACE: FAU�_G VitY � - � � � IICENSED CONTRACTORS DECLARATION � 1 FLOOR BTU lO 0 � ' � � �1 0 d.9 A I hereby offirm�hat I om licensed under provisions of Chapter 9 SUSPENDEO UNiT- . ' . HEAIER: WALL e a •i � `(commencing wifh Section 7000)oi Division 3 of Ihe Business � �'• 8 ' } and Professions Code,ond my license is in full force and effect " � � � � - � � � - 0. 4R0544 Re isters 1. 1 1+•4 b P 5 O . Ltcense Number Lla Class L'-2� -- �-; � ► � . U Controcfor_R&riChO AiT�IriC.pate 8�15�87 , �p �4�2 5� O � 0820-86 v I am exempt under Sec. y� Plan check fee a B.8P.C.for this reason� � ' Z PERMIT ISSUING FEE S 10 0 Oote; 5gnature TOTAL FEE OWNER-BUILDER DECLARATION � P�N CHECK APPIiCANT � ,. 1 hereby affirm ihar I am exempr from the Conrracmr's License , , � � . Law for the following reason(Set�ion 7031.5, Business and NAME � � . , , �`essions Code): � -- ; � A�DRESS u I, as owner of the property, or my employees wiih � woges as their sole compenso+ion,will do the work ond " � � the strutlure is no�iMended or offered for sale(Section CIiY TEL NO. , . 7044,Business and Professions Code). � � �� � � �-- ' owNea T Anden Grou . ❑ I,as owner of the properfy,pm exclusively controcting � , , � , with licensed controctors to construct the project(Seo- � �"�`�� - � � - - �-� � " . tion 7044,Business ond Professions Code). AD�RESS 10 4 P�arkviecr Drive #/201 . CONSTRUCTIQN IENDING AGENCY -�- air: ' � �� - --- � tEl.N0: - I here6y affirm thal ihere is a mnstruction lending ogency for Covina � � 67-9541 , � the performance of the work for which this permit is issued �OntiRnCiOe �� ' � ��--� (Sec.3097,cv.c.�. . . Rancho Air Inc. � . , __. - --- _- - _. nooaess 1232 W. 9th St. _ � Lender's Name � Lender's Address � - � CITY . d _.._.. TEL.NO. 81-�8�l . -.-: � , , -� I cerlif ihat I have read ihis a lication and slafe Ihol ihe STATE LIC. � � Y PP � LICENSE NO. .. Ly .. - CLASS �C-2O --. . ... - . -. . . . . . . .. .. .. . .. ..... . ..:. . above information is correct.I agree to comply with all Counly ord�nances and S�me laws relating�o building construction, _ , � and here6y aulhorize represeMatives of this County to enter � � �- �� � �� ��� -- � �� ' ' � -- --- - � on the abo�e-meniioned properry for in pecrio purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE _ _ -4- - ,�. --�_ � 1 _ � � - Signat�re of Applimn�or Agen� Do�e . . . ... . .. . . . . . . ..-. ._ ...... . . . . . __. _ . . _ x . � . . ;{..� , .,. - - .,.,,_... _ _ � '' OWNER-EUILDER DECLA�ATION ,. ' � IN31'ECTOR'S NOTES . • --- -I hereby affirm thot-I-am e empl From the CoMrac(or's � -�� -�^� �• � ���� License Law fo�iho�follo+.v'ing recson�(Secfion 70JI.5, ,.... ._.._.. '_'._..__._._ ..._.__._..__..,__..._. ..... ..-.. ._..._..___....,.,..._ ._ . ._._ ..._.. . ..... ..... . BvsinessandPro/essionsCodc):AnyUfyorrovnfywhfrh ' � . . .. � � � �� � � � �requlres'a permlt to construcl;oHcr,improve,clemolish, -- - -- �---. --� - - - � � - � - � � ' ' � ' or rePalr any sfrucfvre, prlar lo Its Issuance, also re- ; � � . - � . . � . � � �':'���'�" , - � �. . �.qui'resTheapplteariiforsvcMpermiftolileasignedslale- � �- --- �- ---�-�- --- �� - -- - -- � ' � � � �- �� �- � - ' '�� � menf ffiat ho fs licensed pursvanl}o ihe proNsions o!ibe �, � .� ContracfoYs�Licenze Law(Chopte�.9(rommendng wifh __.�,_ _.. ........._ ....... ..... .. .. �......... .... . • � � : . �. ; SeUion 7000J of Divlsion 7 0�fhc Bvsiness and Pro�es� . � �. � - � � . � "� sions CodeJ or,fhot he Js eacmp�fhere/rom:and Ihe b'asis . . � � . � � � . for fhe ollec�cd exemplion Any violaflon�o/Sectian � , ��. i... ._'. . . _ " ` �,. .._. _ - � '� � ' , ,� 7031.5 by onY�PP�)conf/or a permii subjecl3 1hc dpPli' . ---- -_.. � . .__. _ . __ . , . . . ' . . . ,., . . . ', .-.._._. _ .__._ ' . �" . . � canf lo a civi!penofty of not more.fhan fivo hundred � � � � -� dollars(5500).: _.- ---_. .._--�--. . _.__.. _. � , ' � ;�. ._.. ,� . ' � _ . -.-- �.'-�. :-.. . . � ' .. � ❑I,as owner of thc property will do the work,and . _._ . _ _ __... �:- - ' -';,:. ' - -�,'- �- - �-�- � - , � , "� -Ihe slructure is not intended or offered for sale.-�� � 1 ,_ \� . . , . - . � � 5 �-�� . ._�� • ��� � � � � ' � (Sec.7044.BuslnessandPrafesslonsCode'�TheC�„�ao- ... _ , . .._.. ._ ... .. , . , �. , . ,. , � , , ,lor's Lltense law�does�nof opply topn owner af property ---- --- - ' .:who.6uilds or.lmproves,�hereon„and who does,such . _...� ._.___ _ . ..._ ._ _ .. . .� � � , . _ . . . . . . - work h(msel(provlded tbat such improvemenfs ore not . .. ' �' .. ' � Intended or olfcred Ior salc-I!.however.ihe bu7lding o� � � __._., _. _._ �. . .�.. Improvement is sold wlthin one year of complettan,�he � �� �� • � : ' _. -� ---� � � � __. � � awner-builder wlll hove ihc burden o/proving that he did � . . � � not build or lmprove far Ihc purposo�ol sale.)� � , " „'- � ��-- ' ` � -'- � � � ,,.� ❑K:ps owner of thfl property,am exclusively con- . � � ' . � . - rractin 'th licen.ed controctors to constroct the projecr .� � --- -� --�- --- -�-- � - � (Sec.7044)6usiness and,Fro!esslons Code:The Canfroo � . � , ' ' � � - � tor's ticense 1aw docs nof opply�lo art owner oI properly � ' � � - who 6u71ds or improves ihereon,and who confrocfs!or , � - � � � - '-' � ' �such pro(ecfs with a conlrocfor(sJ 6censed pwsuan�to '' . ... . _. . _ � __ . _ .. - - -- _. .._ � -. , , � . .... .. ......... � - ---the Con}ractor's Ucense CaJ�). � ' � . . ,_' . ___. . . .._. . . �,. . � � � � � � '� I pm ezempt vnder Sec.� � � . . i . � , . , .� �- B&P.C.�for lhis rcason ' — � - --`------.__.--'_ .- . . .. . , .. . , . -- -- -- - - - - -- ' �atc , , . .� . . . ` � . ,� . ., ,., .� . �i� , ..� , . . . .• _ ..' _ Owner , INSPECTOR'S NOTES • � _QJ�'�>,t'`i tJ .09�.:ls�ci..�� �,':.r...�.Nv'���