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HomeMy WebLinkAbout1678A (10) . 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 . �. . . � .- . . . . . . :.. . -.. . 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