HomeMy WebLinkAboutNo Permit Number (11)WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lob. C.)
Policy No. F17107 Company Fairmont
Certified copy is heteby furnished.
n - Certified copy is filed with the county building inspec-
tion department. _
Date S9ci'f 86—Applicant RANCTIO ATR TNC.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not be completed. if the work involved by
the permit is for am hundred dollars ($100) or lass.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any personinany manner
so as to become subject to the Workers' Compensation Laws.
Date —Applicant
NOTICE TO APPLICANT: If, after makingthisCertificate of
Exemption,- you .should become subject to the Workers'
Compensation provisions of the Labor Code,you must forth-
with comply with such provisions .or-thWpermlf shall . be
deemed revoked. - -
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9
commencing with .Se€iion7000) of -Division 3 oftheBusiness
and Professions Code, and my license is in full force and effect.
License Number 380543 Lic. ci.0-20
Contractor RANCID ATR IN"e 8/31/85
1 am exempt under Sec. -
BARC. for this reason
OWNER -BUILDER DECLARATION -
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
Professions Code): - - - - - - -
1, as ownerof the property, or my employees with
wages es their solecompensation, willdo the work and
the structure is not intended or offered for sale (Section
7044, Business and Professions Code).
1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
Sec. 3097, Civ. C.).
Lender's Name
Lender' ddress
I certl at I have his application and state that the
oboe mf rmatio come . I agree to comply with aII County
ordi a s u State la relating to building constructi n,
an reby -z r sentatives of this County a ter
he a -m roperty for i speck n r S.
ignoture of Applicant or Agent Dote
APPLICATION FOR PERMIT
76A3W HEATING - VENTILATING - AIR CONDITIONING
CE - 818 (REV. 10/81)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
PRINT OR TYRE ONLY) _
BUILDINGADDRESS 951 LO
LOCALITY DLAliOND BAR,TRACT 35581/2
NO. TYPE OF APPLIANCE OR EQUIPMENT - FEE
CROSS ST. LOT 82
ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED 8Y
AIR HANDLING UNIT, CFM
BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE
COMPRESSOR, BTU 48-000 0. 00 ROUGH to„
2 - VENTILATION SYSTEM 12 ` 00 FINAL rzJ-16JeT%J
EVAPORATIVE COOLER
110.
VALIDATION
221.2A
8
6 S 2 5
6 5 2 5
0& 15 -- 8 5
FURNACE: FAU _GR VITY
1 FLOOR BTU 10. 00
HEATER:
SUSPENDED—UNIT— USPENDED UNIT_
WALLWALL
13 EF11TSTERS 1-75 22 75
Plan check fee
PERMIT ISSUING FEE $
TOTAL FEE 5.23—
PLAN CHECK APPLICANT -
NAME
ADDRESS -r
CITY TEL. NO.
OWNER-
ADDRESS 1074 PARK VIEW DRIVE. l 201
CITY COVINA,CA TEL N,.967-9541
CONTRACTOR RANCHO AIR INC.
ADDRESS 1232. W. 9th. ST..
CITY UPLAND CA. TEL. NO.
984: 48
LCENSE NO. 380543 C C-20.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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