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HomeMy WebLinkAbout1677A ,WORKERS'COMPENSATIONDECLARATION - . APP�'CATION FOR PERMIT � � I hereby alf'nm lhat I have a terlifimfe of tomeN to self � , Insure,or a certi(itaie of Workers'Compensa�ion i�:�,a��e, � - � HEATING - VENTILATING - AIR CONDITIONING - � or a cerlified copy thereof(Sec 3800,Lab.C.) 76A36aC . � rwC o506�� Golden Fagle Ins.��eie�e¢v.io�eij P❑olity No, mpany .. . . . . . . . . . . Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY � � Certified wpy fs filed wiih the county buflding inspec-- � � FOR APPLICANT TO FILL IN � � � sui�oiNG tion departmenL � (PRINT OR NPE ONLY) . ADDRE55 711 Pantera Drive Date 5-29-A9 �� nPPucoor-�R na— h��r, Tns- - 1O�i°rv Diamond Bar Tract# 42582 NO. TYPE OF APPLIANCE OR EQUiPMENT. � FEE CERTIFICATE OF EXEMPTION fROM WORKERS. - cR055 57. IAT/{ 11 Job�{ 876 COMPENSATION INSURANCE � (Thli s�cfion noad nol be compl�}ed ff fh�work involred by ABSORPiiON UNR,BTU DISIRIC7 NO. VRp�E55ED BY the pormlt it For ona hondrad dollars(5100)ar lass.) � AIR HANDLING UNIT,CFM �/�� ` ^ I certify thal in tha performonce of the wo�k for which this . �O 1 � �GL`�11 e ��permit is issued,�sholl nof employ any person in any monner BOILER,BTU ' — so'os ro 6ecome s�bject to the Workers'Compensation laws.. nPvaovnts �4TE INSPEC�ORS S�GNATURE � �� � � � �- COMPRESSOR,BTU 60.000 ].O. O ROUGH , � Uafe � ' �+PPHcant NOTICE TO APPLICANT: If, after moking this Ce�tificare of vENTILA710N SvSTEM F�NA� _ $ ption, you should bemme sub[ect to the Workers' . pensallon provisions of Ihe Lobor Code,you musf for�h- EVAPORATIVE COOLER VALIDATION � wd comply with wch provislons or this permit shall be deemed revoked. � � � � ..� -� � .�' FURNACE:. FA � RA I �- - � � LICENSED CONTRACTORS DECLARATION � 1 FIOOR � � 0 ZO. O - I hereby o((irm fhm I am licensed under provisions of Chapter 9 HEA�; SUSPENDEO UNrt_ - '(commencing wilh Sedion 7000)of Division 3 of ihe Business ' �'A« � ond Professions Code,ond my license is in fuil force and effetf. , - -- � � � y 1 Re isters l. Ea O license Number 380543 �;�.eia„ C-2o , �� 6 7,�Fl � RSnCho Air� Ix�Te 8-31-89 O Contmctor � . . • � o #.: .8 � -I om exempf under Sec. W Plan check fee I � 0 5'a 2 5 N B.Bv.C.fot this reason _. . PERMIT ISSUING FEE S 10. 0 � s ��-� x z � Date: J'2 5"� Signoture TOTAL PEE �9,.�Q-&8 � OWNER-BUILDER DECLARATION� PtAN LHECK APPtICANT . . � I hereby aftirm thot I om exempt from ihe Confrotlor's litense - - , ►� Law for the following reoson(Section 703I.5,Business and NAME . . . P^rofessions Code): � � � � � . - � . ' ` I,o5�owne�of Ihe property, or my emplayees wifh E+�DRESS� � � � - � � jwoges os their sole compensation,will do the work ond the slruUure is nol intended or offered for sale(Seclion CIN TEt.NO. 7044,Business and Professions Code). ,. OWNER � � ❑ I,os owner oi ihe property,am exdusively contractinq �� . with licensed confmctors to construct the projec�(Sec-- ADDRE55 1074 Par�view Dride �2�1 � � tion 70dC,Bosiness ond Professions Code). � CONSTRUCTION LENDING AGENCY. � -�� �i7y � � - 7EL.NO.� � I hereby a(firm that there is a cansfruttion lending oqency fo� � COV1II8 Si8=967-95�+1 �. Ihe performance of fhe work for whith�his permit is Issued GONTRAGTOR R��� �R IRL•. , (Sec.3097.Civ.C.). � . . .. . . - .. __.. ._. . . . ___ _._._.. .. ... .. - ....., , ._ . aooRess 1232 W. 9th Street � Lender's Nome . . .. . ._ .. . _. _ . , _ . . CITY. UP18IIC� TEL NO.'TZ!{-95�.-4SO1 _ __ _.... . . . . _ Lender's Address ' . $TATE 1. UC. - I certify Ihat I have read Ihis applicaiion and sfale thaf the. pCENSE NO.� O 43� CLASS C-2� �- - � ------- - � � � --- - -- - above information is correct.I agree to comply with all Counry � � ordinances and S�o�e laws relating to bvilding tonslrutlion, • ' and hereby autho�ize represento�ives of�his County�o en�er � � � � �� � ��� � � upon a ove-menti ned prope�ty(or inspectfo�purposes. ' SEE REVERSE FOR EXPLANATORY LANGUAGE _ o��ra.� �-ay g� Sfqnofure of APPlicont or Agenr � � Doie .� .. . . . . . � . -_'. .. . . '�- --- . . .. . . �� ' '\... ` ; ' � .. � . -�� , . �, �', �1 �. , . � � ,- �, �_ \� ,R . ; `, ! ,r ,.`: '�,\ -._. - '� . ._, ,. . �\�,� • �. ��� ` " - ,' �. � ; . ', . � ,. . ... . . . _ . _ , . .;, ! `.z _ ''� ', ` Z � ��� � ' ��� �� ��', � � � -�'o � __ - ,�- - " . � � � � � , � � � � ��• �`t�. �; r , ; � . ' �4 , . � . . ` . N �. ' - • �., ... ,` — ' - ,t , . ` 1 . . 1 } . _ �' - , . , i e , . . '. �'+ \. .,\ � . . � . . �� . ' � � 1 � � `� . 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