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HomeMy WebLinkAbout1680A (10) .WORKERS'COMPENSATIONDECIARATION � APPLICATION FOR PERIY,IT � I he�eby aifkm thot I have a ceriifica�e of tonsent to self insure,or a certificma of Workers'Compensarion Insurance, HEATING - VENTILATING - AIR CONDITIONING or a cerlified ropy thereoF(Sec.3800,-1ob.C.) 76A36aC � CE.616(REV.10/81).- .� �.' . . ... O�yNo.pwc o506��„��Y Golden F.agle Ins.. CertiFled topy�s here6y furnished. COUNTY OF LOS ANGELES-. BUILDING AND SAFETY � Certified mpy is filed with the county 6uilding inspeo- FOR APPLICANT TO FILL IN BU4DtNG lion deportment. � � (PRiNT OR TYPE ONLY) � /DDRE55 677 Pantera Arive oaie ApplicaM LOCALITV Diamond Bar TractH 42582. NO. . TYPE OF APPIIANCE OR E�l11PMENT � �� FEE CERTIFICATE OF EXEMPTION FROM WORKERS' � -� ceo55 S7I,OTN 1� Job# 876 COMPENSATION INSURANCE - ' qB50evnON UNiT,BTU �(Thts�edlon na�d not 6o eomplatad ti tha work Involved 6y- oisrzia�o. vaocesseo er tho parmil Is for one bvndrod dollan(5100)or lats.) qIR HANDLING UNIT,GFM 1 fi (�[\ � I cerlify-Ihaf in the performance of Ihe work for which this� �(J i�t�\Q(1� � permit is issued,I shall nol employ ony person in any monner gp�lER,BTU — — �so os ro become svbject to the Wo�kers'Compensation Laws. navrsovn�s onre INS�EQOR'S YGNAfURE 2 COMGRESSOR,BTU�36.�0� - 2� �0 ROUGH b�� Dote � � Applicant � � � NOTICE TO APPLICANT: If, after making Ihis Certificate of - VENTaATION SVSTFJN FINAL Z '�q�ption, yo� should become subject �o �he Workers' . �W Jpensotion provisione of Ihe Lobor Code,-you musl forth- EVAPORATIVE COOIER VALIDATION 16 compty wiih such provisions or this pe�mii shall 6e deemed revoked. .� - ' � . � ,2 �L�RCE: . , FAu���v�TYo— .20 00 LICENSED CONTRACTORS DECLARATION � � U . � I hereby affirm ihat I am licensed under provi5i0n5 of Chapler 9 � HFATER: SU57ENDED UNIi_ .�(commencing with Settion 7000)of Division 3 of the Business ' WA« and Professions Code,and my license is in(ull iorce and eifed. � � � a 1 Re isters @ 1. Ea 26 2 0 380543 C-20 ► �1 6&G A � License Number Lic.Class . � ;�.: . . .g o eo���acroRancho Air, Inc.DateB-3�'-89 t- � I am exemp�onder Sec. - - .. � � � •�7�7 J` a Plan check fee 7 6'J�� Z 8.8P.C.for Ihis reason' . . . �� . l0 50 . .s i s PERMIT ISSUING FEE S Dote: Signature TOTAL FEE 6 0 9.[�—8 8 OWNER-BUILDER DECLARA710N � PLAN CHFCK APPLICANT , � , 1 hereby offirm ihat 1 am exempl from the Contraclor's License , Law for the follawing reaso�(Sedion 7031.5,Business and NAME ' . Professions Code): _ . � I, as owner Of 1he property, or my employees wifh ADDRESS � � � � � - wages as their sola tompensaiion,will do the work and-� ��T, TEL NO. ihe strocture is not intended or offered for sole(Section � 7044,Business and Prolesslons Code). � - � - --� � � O'NNER . � � ❑ I,os owner of�he property,am exciu5ively conimcting wilh Iicensed conimdors to consfrvd�he project(Sea � DDRESS 1O71F,P8S$Y1Ctd DT1Y@ �Z�l � tion 704d,Business and Profeseions Code). . CONSTRUCTION LENDING AGENCY . � -� ciiv � �Ca��� � - �TE�_No.81$-9F)7-9541 I hereby affirm Iha1 there is a consr��ction lending agency for , � Ihe performance of ihe work for which this permN is issued �ONTRnROR �N�� �Re�IRC• � -" -�� � � (Sec.3097.Civ.C.).� " � . _. . .. . .. ... . . .._ ._.._ � � ADDRESS � ZZ3P j'�. 9th Street -- - � � -��- --�-�- -- � � � � - - - Lender's Nome . .. ie�aer5 ndd.e5: arr Upland Te�.Ho.714-981-4801 _. _ . . . . . STATE - LIC. � I cer�ify thaf I have read fhis application and stale thaf ih0 UCENSENO. � �i3-� �CW55 (,'�'�Q ---� � � - - - above info�ma�ion is correcf.I ogree lo comply with all County . � � ordinances and State laws relating to building construttion,, � . . _ - _ _. . _ _ and hereby ouihorize repiesentmives of this Coonly to enter , � � �� � �� - �' � -� - � upon tf o ve-mention p�ope�ty for inspedion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE , �?���o �-ay:�' _ _ -- . ___� __ SignoNre of�ApPlicanfor Agent . 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