HomeMy WebLinkAbout1256A WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PERMIT �
I herAayaoffirm that I hpve o certificate of tonsent io self _ . . ,
insure,or a<errifi<ote of Workers'Compensation Insurance, bA�� HEATING - VENTILATING - AIR CONDITIONING
or a c t�ie c py rh revf(Sec.�3800,Lab.C.) � �
����4-1� Employe25 Benifits ce-e,s;aev ioisi)
P❑ollcy No. Compony ,
Cerrified c6py is hereby furnished. COUNTY OF Lp$ANGELES BUILpING AND SAFETY
� Cerrified copy is filed with the c�n��buediryg;nspe FOR APPLICANT TO FILL IN BUILDING
tiondeportment. �;J (PRINTORTVPEONLYI P.DDRESS 22615 i.ic1Z Meadow DT.
Date 7-1-89 Applimn ����� - � �ocauT� Diamond Bar
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTI PROM WORKERS' . NEnREST
COMPENSATION NSURANCE CeO555T.
(This section need not 6e compleTed if The work involved 6y /+gSORCTION UNiT,8TU o�srRicr No. aaocesseo sv -
The permit is for one hundred dollors(5700)or less.)
I certify ihat in the performance of the�work for which this AIR HANDLING UNiT,CFht � (7 (�-r—
permii is issued,I sholl not empioy any person in any manner gpILER,BTU
so as to become subjecY to the Workers'Compensa�ion Laws. j A?PRovn�s �arc iasaecroa'SSiGNnTuee
Date Applicant / CON�PRESSOR,BTU� � -� �'OUGH
NOTICE TO APPLICANT:lf, after mokinq this�Certifimte of vENT�LATION SYSTEM FiNAL �.
Exemplinn, you choiJd 6ecome subject to Ihe Workers'
��Compensation provisions of�he Labor Code,you must forih- EV.4aOR.4rNE COO�ER VALIDATION
with comply with s�ch provisions or ihis permit sholl 6e �
deemed revoked. FURNACE: FAU_GRlqyIT���_ �
LICENSE�CONTRACTORS DECLARATION F�OOR B7U C!Pf
I here6y affirm ihat I am licensed under provisions of Chapter 9 HE.4TER� SUSPEN�E� UNI7_
�(commencing with Section 70001 of Division 3 of the Business WA�
and Professions Code,and my license is in full force and effecf. � �; \ � !�, - �
C1 ' dJ Q
License Numbe�-'r 151.03 � Class C2� ` , V
�7-31-90 �i ��,6A p
conrrac+g � J . ��� m a �, ;;; t~i
❑ 4 am xempt under Sec. � �
Plcn check fee
B.&P.C.for ihis reason � " °.�.H,G J� �
PERMIT ISSUING FEE S .�
Dare: TOTAL FEE `� `� ^ `:'[``
Signoture
- OWNER-BUILDER�ECLARATION PLAN CHECK APPLICANT ��`4'•" � ��5
I hereby afflrm that I am exemptfrom ihe Controctor's License � ,
Law for the following reason(Section 7031.5, Buslness and NAME
Professions Code): � �
❑ I, os owner of ihe properry, or my employees with AD�RE55
� wages as their sole compensotion,will do the work and � ����
ihe sir�ct�re is nnt intended o offered for sale(Section C�,Tv TEL NO.
7044,Business and Professions Codel.
owveR lhe Country Estates Assoc.
❑ I,as owner of ihe property,am exclusively wniracting . . . . . .
with licensed contraUors to wnstrud the project(Sec- M/+LL
!ion7044,BusinessondProfessionsCode). .qDDRE552ZF715 Lazy Meadow� Dr.
CONSTRUCTION LENDING AGENCY CI7YD11IilOI1C1 Bar TE�.No.861-4114 �
I hereby affirm thot ihere is a construction lending ager.cy for
the performonce of the work for which this permii is issued CONTRACT�OYI.R A. Martin Ht0. & A��.' ,
(Sec.3097,Civ.C.). � . .. . .. .
� ADDRESS �[�Z W. Bonita Ave.
Lender's Name ����
��T�San Dimas, TE� No599-2901
Lender's Address � � . . �
I certify that I have read this app!ication and stote thar the ST"TE 315103 - � "�� C20
LICENSE NO. C1A55
above Information is correc*.I agree to comply witn oll CouMy -
ordinances and State lows relatir.g to building w iruction, � �
❑nd here ut or representatives of ihis Cou y to.enter .
e- e `ned pEwy*�far�in n pu pose. . S�E REVERSE FOR EXPLANATORY LANGUAGE
�G' �
Si oiu�e of Applicor.l or Agun� D c
. .w,.wwa�...m.,.�....e:-,>,�........�,..,..-.�:�:.�.a:..-+�.v�..-�,��.��,..�c.nnF.n,s�m---,«r.:�a*ew-��-.n•,.�.,,:.-,F:—.,.r...:xi�,-:-.,.�,-_..-.._.-;c.c..+..-.�-- — �
lN3P&�TCSR'S Rc3T�� — OWNER-BUIL�ER C�CL,GRP,7iON
I nerehy arfirm fhat i am exempt irom tl�e Coniractc%s
� � -�' Licei�se Law For ih� followinn reasan (Sect7on 7031.5,
' � - �� . � - 8usinoss cnd Professions Cudc;:Any city ur ccur,'y v�F,ich
� '—�--�-�----- -- imorovc,demolisn.
. � �� � �' �- �� . reqvi�es a pe�mi!fo construcf,al;er.
- � � � ar�repdir any.strucfure, prior to i�s rss✓ance, oL-a re-
� . - �. � �� ' , �q�ires ihe Dpplicanf for sucfipermif to fil=a signed stc'e-
� -� � � ment Pho4 ha is licensed pursuon��to 1he provisions of she
. � Con?roc+crs Licerse iaw(Chapfer 9!commencirg with
- � � Secriun 7000;oF Div' n 3 or'ite;:usin��ss end r'rofes-
rs�c
—_____._.__ __" . . �. . . ... .
- ��sloos Code;or tFaf 6e is exenpi tner��from on�the basis
- � for fhe al;�,qed ezamp;ian. Rny violc�ion oi $ecf;or.
, . . . .. -- — 7031.i bv ony oppliwnf tor a p2�mi!sobjec,'s iha opnll..
- can! !o a c'rvil penaHy of not rnoi'e.tban five hundred
_ . . _ _.—______—...__ . — dcllc�rs!35P0;.: � . .
. . . � � � i�'- , of 7he properry w�iil ao tne a�aork.a::'
. � � ine sir:;cture is no°rinlentled or oifered fo�sa!e. �
- - � �� � � � � ;"5��.7�4!',8usinessandProfessronsCode: 76eConircc
� � _ . tor's License 7.mv does nof apply ta ar,owner o4 properly
�� � - who builas or improyes.'rhereen. ond vihc does such
- � � �� � � � +ork himsz!f crcv"rded ehc9 su:h improvemenis cre no;
� - � - ir;fended or of4ereA for sale.!1.hmvevcr.t'r.e building o:
�� � � improvemeni is sold�vifbin ons yecr c1 compie9ion,the
� owncr-6uilder wNf hqve the burden o£pr.oving iho}he did
� . . - ' � noi bu!!d or'rmprove fcr th�,ourposs od mle.) �
� � � _ _____ ❑ I,as ov✓ner of the prqperty,om�xdusive!y con-
� •rccti�-�g�,viih ficensed cenirac��rs to ce ucr ihe�projeci
ns:r
� ' !Sec.7pc4j.Buslness.ard Professions Cqde:Thc Cc�,i:ao
—� — _—_—_.__—___—_—._—__ .� �. . .
- ror's Licer,se`Law does nc!a�piy;o an ownc,-of urepart�
- ___ _ who bui;ds or'rmprovzs.;herean,ar,d wha ron'rrocPs 9or
� such projecfs wifi;a confredor(s)licensed pursuan;?o
fhe Confrector's Licensa Ccwj. �
� I�m exemplUndar Sec_:,___,.__________
B&P.C.for this reason ��� �
� . � � . . �ate �
— — . Q•.,�ne� . . .
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