HomeMy WebLinkAbout1678A . WORKERs�oMPENSAr�aNOE«ARAT�oN �� AppLICATION FOR PERMIT j�
I hereby o(fkm that I have a tertificote of tonsent to self � �
insure,or a certificata of Wo�keri Compensation Insurance, ;�bdc HEATING - VENTILATING - AIR CONDITIONING L�
'or a cerfified copy thereof(Set.3800,lab.C.J � �
.. CE-819(REV.10/elJ - �- .. . --
acyt�oPGTG 05061�-ompanyGolden Eagle Ins.
Certified copy is hereby furntshed. COUNTY OF LOS ANGELES BUIIDING AND SAFETY
XO Cer�ified copy is filed with ihe counry tiulld�ng tnspeo- - FOR APPLICAN7 TO PILL IN euuowG
tion departmeM, � (PRIM OR TY7F ON�Y) - ADDRE55
Date�'j_-2Q—�Q� Applica�b2anrhn �Air� Tnr_ � ����n' Diamond Bar Tract# 42582
' NO. TYPE OF APPLIANCE OR EOUIPMENT � � FEE
� CERTIFICATE OF EXEMPTION FROM WORKERS' NEAaEST ,
� �� COMPENSATIDN INSURANCE � CROSS ST. I+�'# 1Z —��P/� JObN STC
(Thfi sstflon need not ba complatad ff ih�work Involved 6y A650RP110N UNIT,BTU �ISiRICI NO. PRp�E55ED BY
the parmit Is for one handred dollars(5100)or lets.) - � - � D A_ \
I[ertify thot in 1he performance of tha work for which this A�R HANDIING UNIT,fFM n j\� �n�
permit is iss�ed,I shall not�employ ony person in ony manner - �
� so as fo betome subjecl lo the Workers'Compensalion lows. BOILER,BTU� nvvaovnts onre INSPECTOR'$$IGNATURE
� DO1e � �. � ePP�.�o��� . 2 COMPRESSOR,BTU �6.000 2O OO ROUGH 0���
NOTICE TO APPtIGANT: If, af�e�making ihis Certifimte of VEMILATIONSYSTEM F�r1/+� rz•(�'
�mption, you should become subject to the Workeri
mpensation provisions of the Labor Code,you must forth- EVAPORATIVE COOLER VALIDATION
� �with comply with soch provisions or this�-permif shall be . � �
deemed revoked. � � � � �� � � FURNAC& FAUap[_ VI
� � LICENSED CONTRACTORS DECL4RATION�- � Z FLOOR e7U� ZO OO
I here6y affirm ihat I am licensed under provisions of Chapfer.9 . .SUSPENDED UNIT_
HEATER: WA��
�'(commencing with Section 7000�-of Division 3 of�he Business �
and Professions Code,and my license is tn full iorce and effect. � �
Ucense Nurober- 38051+3 uc.Closs C-20 t r l. Ea 26 2 - p
. �16Z8A "
co�+�acio.Rancho Air. IIICDaIe 8-31-89 a
#. : .,. .g o
� v
I am exemp�under Set. . Pldfl CMECk fC6 � � � � I d i'](1']5 a
B.&P.C.for this reason' pERM1T ISSUING FEE s �-� 5� ; • •']�,,']rj� ?
Date:
Siqnmvre TOTAL FEE 6 D 9.2 0—8 8
� OWNER-BUIt�ERDECLARATION � PIANCHECKAPPLICANT .
I hereby affirm rhal I am exempt from the CoNractor's license , � .
law for fhe following reason(SeUton 7031.5,Business and nl.4ME .
Professions Code): � . - " �
� I, as owner of the property,or,my employees wilh ADDRESS �
wages az their sole compensation,will do the work and Cltt TEI.NO.
-the strucfure is not intended or offered for sole�Settion
7044,Business and Professions CodeJ. . -� -
- - � OWNER �1C AIIC�G'II Group _
❑ I,as owner of the property,am exclusively contracting �`
with licensed tontractors to consiruct the project(Sec- � qD�RE55 1074 Parkview Drive �24�- � �
�� -�ion 7044,Business and Professions Code). ' �
CONSTRUCTION LENDING AGENCY CiTY �a,ri�� ��.No.818-967-9541 �
I hereby affirm�hat ihere is a conshuction lending ogency for .
the periormante of Ihe work for whi[h this permit ia issued �pMRaCTOR � ��—� ---� -- ,
(Sec.3097,Civ.C.). RANCHO AIR INC.
— --' — __ _
..
aooaess 1232 A. 9th Street - . . _ _
Lendei s Name
_ aTr Upland rei.No.714-981-4801 _._ . ._ . . _
lender's Address . .
STATE - IIC.
I certify lhat I have read this application and s�ate thal the IICENSE NO. - � �l3 CLASS � C-2�-.. _ .
. _ . _'__ ._.. . .... . . ...._ .
above informotion is correct.I agree to comply wilh oll Co�nty .
ordinanms and Stafe laws relating to boilding construction, : - �
and hereby authorize represeMatives of this Coonty to enter . - - -- - �" " � " -"" - � -- '�- �� - - �-� � � -
opon e ove•menli ed property for inspedion purposes.
���� ����� SEE REVERSE FOR EXPLANATORY LANGUAGE
SignaWre of Applimnl or Agr.m � Dare . �. . . � .- . . . . . . :.. . -.. . ' .- --�- �- - � .. . .
�-- ." i ' � 'j
•,
� ;� 9 ��, i
;,' 1
�. _ �} r ;
� . `, �' ; �_ .. � ,. � ; .
,:. .. � � -
, .
� � ' � -- • ' ' ^ �e r�
. ' ' �� .. . 1-" _ - }. 1 '
� i...". ' ' , , ' ' � '..
� . J..- - , ,. . . . '
:i . ' � . � . ^": , 1
�o_ � ,__ _ �t� � � . � .
� ` i:. !��
O l , : . °;
N • , .
, � _ t
, , - _ �;
- ��" , _ � . '
. . t .._ � 1' � ' , ,. .. _ '41 .. ' .
. }` . � _. ' � i � • : . .
•`� j ti �� `�� �
�� N
� ' . ,�'' .,i _ � i �O
��� � �y , �
� �'� -.'� �1 '�' . _ .. -+, �
``
, ' ' ' ' z
�' ��' ��! �'� ' , ' � i��� � � �< �� o
, , �.
- � ,� 4� .� , ., 1 '�i
� +� t� ' '� '
t.. -
� 11' , • ' .
` - .
.� , � :� ��.�
t i
� ° � � mm
� . ! : _ N.�,Cl3C � �^ �
�� ,� ' . . �. �� Q� p"�j� � C-� N N , ..
•' ,
� 4 . . ' �[ .�.N� O Y� M'Q �. N Q N N r�'" O
, � . , ' �. . ' O �� S n. o„ �_^.� rtT S^ p D O Q. ..
.. , � 3 ooN � �� a 'D-o �on ,�. � f _. ��L
. �` • v, a. o f� m ic- .-�� c n.o s�a �'fl o. -.
T C'�'� n =. �i O 0.TC i� ���V+O�C p vpo�,;�p.p � �D-,p p�,' �
'�' ,I �D S� � � � �1 6. � A'C � O n 7�.c�'.Q�+�N�N 3 O T, 'I�
', . . �' 3 ' n� o.^o�.t � a�'3o3 �'m.c'm.o�`.'�4-�. o,m -$ ' ' W� o �
. d � o c m.Af'- o m �. o c N -ao.•� Nm �,noN � _ C.
.i _ 0 : o .o` � , � oa�� • o m'-=,`O`a"� 7 � ��° =° � n
, - � � '(�. .� c"o �i°, �, oo�sa 3 -• Mmv f �'oom �-O x_T'N��o� 7Nop �
1"'-� ' • _ m 3 oH ° a� nfv �.« o <�'oH � o n° 3 �-o;° a'� �' = n° 3 ^' ,
" ,. � 'a �£ f"� � � o =�cia,-, o a .�= "� =��'^ � �c •�,'n � o � % ' �
m � C T 0..,,�p O .a"�.� S t9 -7'+ y o.j m-' �
'��.'; � �., s c � � �� °-'� � Q t � n.q � °-a o °,o o �."n c o . �a �:, � .
� . r, s,o m p °'°. o o '�'• a N °�°'° v o ' 3 g.'o.o m � a " ts Cl
, • � :. . w . . � � n N N � o T3.a � a o °, a �.:�; .v...�v;3 o cc 3 0 �. :�, .
(/ ,- � { � . . . . . .. (9 � 11 � O . ^���-m T W � m q�'N �'�{D �('3 j'� ?N,w "`p -' � p p � _
. tP . , Q'O T' '" .n � �
; o, . cv Q,'- �a o o v � ' � ».� o.�o°.K 'o �''� c� � .o s o , 3_K � . � .
< '�N
- � _ . �. ' . .. . ' � ' , ry '' £ O D K�v N � 'D W•G O S� Q �^� f. m y�.O .�� �-� W C � � W 4� ..O .
3
- _ �N? o � 'o? � o„���y,� o'Qaa. fl':a:n 3�N3 �° � m ° o o Z ,
' ' �1 _ - . ' �7 G a.n p �,D p [J O 9'� W � � �'N"p��j.Q �p w 10 �".Q;�� 3 7 .. .
' � _ m �o��� 3 � < o~ 3 s�-�.'-�°m � �n.'a^•N'�o 3<'op- .
.. ;�- . . . . - �. ' . ' . � S�,m C�X ° � 3 4 � ° �p v-��' f S W tn m �� p a o �T;=o
%" . ' � - �o � ?�N 'v=m �N �� o . � a.a-y Q o £s� � _ �,!.+`N �
� . ,. .. •) . _ - " ' ''4 � �,,,W �C � p p-O u+i_"„'S , O a'^p O �^�n T W
� . . . . ' �, m v � �' � �n
. . , �,o 0 o v� � � � � c � n, °- ' �-
ot�� 3o o a.Too T'�
. - - - ' ._. .. . ' - � 7 y' A p � 7 Q.�
. _� � , . . .. . ._ -' p� n Q �
,�/ � ': . . .. :' . '.. �. � � � ��,��� ' o
'• . . _ , �. - : �s��-��
`
, ��