HomeMy WebLinkAbout1679A (10) .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�� .. _ _
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