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HomeMy WebLinkAbout0616A � .WORKERS'COMPENSAilONOECLARATION _�pp��SpT�p�y �pR pERMIT � � � I hereby affirm thnt I have a certifimte of consent to seii y insure,or o certifimte of Workers'Compensqfion Insurance, � o�o�e�+�t�ed�apY�E,e,eor�sE�.saoo,��e.c.� �ba36ac MEATING - VENTILATING - AIR CONDITIONING � CE-816(REV.10i81) � � ��y rvo. F 21 2 comPany_ Fairmont Ins. � Cerfl{ied<opy is he�eby{ur�ished. COUNTY OF L05 ANGELES BUILDING AND SAFETY � � Certified copy is filed with the munty building inspeo FOR APPLICANT TO PILL IN BUILDING a Iion deparfinent. ADDRESS 1030 IQ. H6UT 1255 Pl. i�ot 2 $ (PP,INT OR TYPE ONLY) � �oie 5/2g,�87 apPl��a�r Rancho Air, Inc. - - i�cnuTv � NO, �TYPE OF APPLIANCE OR E�UIPMENT FEE ,D1 .5110 � '" C�. T CERTIfICATE�OP EXEMPTION FROM WORKERS' NEAP.E57 COMPENSATION INSURANCE CRv^Ss 57. A6SORP71pN UNIT,BTU � (This section need nof be completed if the work involved by _-. — oisreicr No PROCESSEO HY "the permiT is for one hundred dollars(SI00)ot less.) �� I certify that in the performance of ihe work for�.vhich ihis AIR HaN�LING UNIT,CFM � ,.„ � permit is issued,I shal(not employ vny person in any monner . - �� � so as�o became sub�ect io ihe Workers'Com ensation laws. B011ea,siU � � APPROVnlS DATE iNSPECTOR'S SICNATl1kE . �- COMPRF.SSOR.BTU �"�1�(1OO ZO OO ROUGH � r ✓'t.>a AppllcaM - _ r �11�'=/7'f� .'�,� � �,�ICE TO APPLICANT: If, afier making this Ceriificate of 3 vENTiLATION SVSienn 1_8 �O FlNnI �(���- �-/ 5 Exemption, you shouid become subject to ihe Workers' — � Y Compensano�provisions of the Labor Code,you must forth- evqpoeqtive cooteR UALfDAT10N � with comply with such��provisions or this permit sholl be � deemedrevoked FURNACE: FAU_GRq—vpY - � LICENSfD CONTRACTORS DECIP,RATION � 1 FIOOR BTu C7U�D-O-O—� .Le OO � 1 hereby affirm thai I am licensed under.provisions of Chapler 9 � SUSPENDEo �NiT_ _�`Q�� ����+`'�. HEATER: �(mmmenting wifh Section 7000)of Divisian 3 of ihe Business WAIL and Professians Code,and my Ikanse is in fu71 force ond effecc �'-�'�'��H °�r°u � 380543 Re isters C 1.75 1 g' License Nunber _Lic Class C—`ZD � 7 , � i`���3�" �� � �7,._� � � Contractor R�ti]Ch0 Eli Y'y121C Dafe ���.1��57 � � u :.n,�h�'-Y�,j � � � ❑ I om ezempt vnder Sec � -- —�. ���7 '� [�.r.�;� � Plcn check fee B.&P.C.for fhis reason- —�--- � PERM17 ISSUPNG FEE S ZQ �p Date '� � 5i9�,��,,,p _ TOTAL FEE �y S � OWNER-BUILDER DE.LARATION � P!AN CHECK APPLiCaNt . � I hereby aHirrn ihoi I om exempt tram ihe CoNraUor's License - , � Law for iha fotlowing reason (Sedion?031.5, Business ond N.4ME . 3 -�,�essions Cade): - - � A��RFSS u� I, os owner of the properiy, or my employees wifh wages as iheir sole mmpensation,�,vill do ihe work and � CITV TEL NO. Ihe siructurc is not intended or offered fnr sale(Section 70A4,Business and Professions Code). - . - OWNER The nnden G�ou � � ❑ I,as owne�of the property,arn exdusively contracting - with liCensed conlroctors to consirud ihe projeci(Ser - MAIL ro��oaa,s�s�ness a�d P�ofes5�o�s codP�. nooeess 1_0 4 Parkview Drive 20i CONSTRUCTION LENDING AGENCY -���QTY TEL NO: _ � I hereby affirrn fhat rhere is a consiruction lending agenty for � — � ► the per`orm�nce nf fhe work for which ihis permit is issued CONTRACTOR �se�.so9�,c�.e.�. Hancho Air Inc. Lender's Name A��RfSS �2 2 w. th S,t. CITY iEL.NO lender's Address Upland _ 9F11-4801 SIAit LIC. I cartify ihot I hpe�e reod Ihis applicalion ond stot=_that the - uCENSE Np. (�, C�ASS (,'-2Q - a6ove information is correcf.I ogree to mmply with all County - -- . - ordinances cmd Stare laws relating to boildirry mnsiruttion. � and hereby authorize representatives of ihis County,to eNer . � _ �pnn�h r,bov=-mc i� d prnperi or inspection p oses. 3 / .,� � � SEE REVERSE POR EICPLANATORY LANGUAGE � G--?'h—� �" � siynature or Applicant or Agen oa�e ' . � _ � - �+ � � � � � a.a � � � ` � e� � , �p � �\ � \ ! �� \ \ �, _ � . \\ � � � � �r ' . .� . A � o w � ��.o io . � N � A N � 1 . V� 4S G{3 �� ��� N �� r' J � � no-3. -�+, 40 "9 40 � � � � � ` ' � O 7 � � { ` � �i� W. �, O � u� Q �n 9 �. \� � \ - .� p�s o?- .U.�'- n3 n c, n% �� .. Z �Q � � � �, U� 'o" �m °n.o°_s.�� � �+ -,�0 3 � - o�� — '-' �,n-c Q _`:Q'" ca.-m`� 3 o S c 7 O P- S G�[� p n U+ . .i l N O Q�- � �N t0 4 � � V. �Z �� (0 n 6'y fp �'.�h G-, U+ O G^}G(''t. -w M St S c0 S . ?� ,�- v+ n � C �D 4-� O_N � _. Ca 5. 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