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
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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 ' .
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