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HomeMy WebLinkAbout1679A .WORKERS'COMPENSATIONDECLARATION APP`ICATION FOR PERMIT � �hereby offirm Ihat I hove a tertiflcole of tonsent to self �ns�re,or a ce�tifimta of Workers'Compensation Insoronca, HEATING - VENTILATING - AIR CONDITIONING Ll - or a certified copy thereof(Sec.3600;Lab.C.) 76n364C � - PWC 0506 Golden Eagle Ins.� 818�R� 10/81) P�olicy No. ��mPony .- . . . . . Cer�if7ed copy is hereby fornished. COUNTY OF LOS ANGELES BUILDING AND SAFETY � Cerlified mpy is filed wi�h the counry building��5peo- FOR APPLICAN7 TO FILL IN euao�rvc 7p3 Pantera Drive � fian deportment � ADDRE55 , � . _ � - (PRINT OR TYFE ONLY) oo�e 5-29-89 qPPiico„� Rancho�Air, Inc. ��+��n' Diamond Bar Tract� 42582 . NO. TYPE OF APPLIANCE OR EOUIPMENT ' FEE CERTIFICATE OF EXEMPTION FROM WORKERS'� �-� NEneESi - COMPENSATION INSURANGE cko55 ST.�r� 13 Job# 876 (This seetton nood not b�comp�Mod ff the woik�Involved by ABSORPTION UNIi,BTU � oiSreiC�No. vaoc[SSED Br the permk i�(or one hundrad dollars(5100)or ber.) � � t 1 certify.�hat in the performance of fhe work for which fhis . AIR HANDUNG UNIT,CPM � �D YV� A\��.e 1`\ � permli is issued,1 shall nol employ eny person in any manner - BOItER,BiU so os�o becoma subject to the Workers'Compensotion laws.._ nvvaovais onh INSPECiOR'S SIGNATURE - '� . 1 COMPRESSOR,BTU 60.000 ZO.OU ROUGH � Date Applimnt . NOTICE TO APPLICANT: If, 8fter moking this Certi(imte of vENTILATION SYSTEM FINA� �, ption, yo� sho�ld become subjed to the�Workers' •'�penso�ion provisions of fhe Labor Code,you must fo�th- EVAPORATIVE CDOLER VALIDA7I�N �with comp�y with such provisicns or this permit shall 6e deemed�evoked. � FURNACE: FAU�G�+ yiTr � . LICENSED CONTRACTORS DECIARATION. 1 FtOOa eiu 1UU-�� lO.00 � � - 1 hereby aHirm fhat I am licensed under provisions of Chapler 9 HEA7FR: -SUSPENDED UNIT_ '(tommendnq wlth Section 7000)of Division 3 of ihe Bosiness - � K'A« �and Proiessions Code,and my Itcense is in full(orce and effect:� �_ - � �� (��,9 A p 13 Re isters @ 1.7 Ea 22. . Umnse Number 380543 lic.Class C-20 . . � - ' �• • . • e 8 V � co�r�ano�Rancho Air, Inctia�e 8-31-89 . I • m 5 3 2 5 � - ❑ I am exempl under Sec. �� . _. _ . - W . . Plan check fee � � •5 a 2 5� N B.BP.C.for ihis reason� PERMIT ISSUING FEE S 10.5� 0 q 2 p_8 8 ? Date: Signa�ure � ' TOTAL FEE 3,2 � OWNEB-BUILDER DECLARATION PIAN CHECK APPIICANT ' ' � I hereby ai(irm that 1 om exemp�from rhe Conhactor's license � Low for�he fallowing reoson(Section 7031.5,Business and NAME � . � . . P�ro-7iessions Code): � � - - ' ' ` I, os owner of the praperfy, or my employees with aDDRE55 � Jwoges os fhelr sole compensafion,will do fhe work ond � ihe str�cture is not intended or ofiered for sale(Settion ��TM TEL.NO. 7044,8usiness and Profetsions Code). _ ' � � - - . OWNER rirhe pnden Gro � � ❑ I,as owner of the property,om exclusively contratting with licensed controdors to cons�rott the projed(Sec- q�'pp�gf55� 1�7�1 PaT�LVI@W DT1.V@��2�1 - tion 7044,Business ond Professions Code). � CONSTRUCTION IENDING AGENCY � � �itt - CQviI18� Te�.Noglg_967-95�+i �he�eby affirm that there is a consrruction lending ogency for ► the performance of ihe work for which ihis permit is issved� �ONTRACTOR ��� �R I�C. (Sec.3097,Civ.C.). � . ---._._ .. . . _.. .. .. ....... .. . . . . � � ADDRESS� -1232 A. 9th Street . . __._._. �...�: � :.-,.. . � . _ . _ ._. Lender's Nome aTr Upland Te�.No'T14-981—b801 __ . _ _ lender's Address I certif that I have read this a licolion ond slole ihol the. STATE LiC. y pp LICENSE NO.-- 3HOS�3� CLASS C-2O --- --�- � ��-�- a6ove information is coveU.I agree�o comply with oll Covnty � ordinances and Stale laws relating to building construction, � - ond hereby aulhorize represenfotives of ihis Coumy to emer . . . � � - � - ` -�- ' vpon t ab e-mention property fai inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �' �?iia,a� 8-�y�� .. _ _ Signuture of APPlimnt or Agenr � Ooie �. . . . . . - _ .. - � _- .. -_. . - i - ' I,t, ,� ` � \ . " � • � � ��� � �'� � . �� �� i` � ? -, � '� ; �\ ` '� ' �4 ... � ,. � ` �/�. +�;- , � `� "•: �. ` '` .: ', �- ,.. �. \: ',���'' - , , �`, ��� '� � . � `.� ',� �.��._ , '�� ' . 1,� ` . ' , : � - ��,1 '� � � �',,, �,'_ � � �.. ,, � � , �: �.. N •`� � . � ,� , ti Z + O '� � - �. �k ; - ' '\ '� • , _ ' '' . - ', �� ^ . ', �� - - " � � �� + - , , '` - �\ Z ,- , , ` - `ra , , ' ' ,1 �i �' O �� ,; � , , l N � � ' ,_ � � � . � � 'i' t V� ' ,', - . �. ' �'� ' 1` l • , . � _ !t ' 11 . . 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