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HomeMy WebLinkAbout1676A WORKERS'COMPENSATION�ECLARATION � I hereby offkm lhat I have o certificate of tonsent to 5e�f ' APPLICATION FOR PERMIT . insure,o�a cerrificate of Worken'Compansaflon Insuronce, �bA�� HEATING - VENiIIATING - AIR CONDITIONING � or a certified copy fhereof(Sec.3800,La6.�C.) �Polit No�C OrjD6�. � - �E-816(REV.IO/81) -. . . . . -.- . . ❑ r �ompanyGOla@II Ea�le Ins. Certified copy is hereby furnished. . COUNTY OF LOS ANGELES BUIL�ING AND SAFETY � Certified topy is Piled with the caunty butlding inspeo- FOR APPLICANT TO FILL IN euaoiNG tion departmeM. . qDDRESS 715 Pantera Drive � �� (PRINT OR TYPE ONLV) . Date 5-2�R4_Applimn1I38ncho-Air� Tnr_ NO. ttPE OF APPLIANCE OR EQUIPMENT � FEE ��AUTY Diamond Bar Tract# 42582 �ERTIFICATE OF EXEMPTION FROM WORKERS' NEnaEST � COMPENSATION INSURANCE Cz055 Si.LOTI{ 7.O aob# 8 6 (ThB s�Nion naad no1 be complN�d(f fh�work involred by .. /+BSORP710N UNIT,BTU DISIRI�1 NO. PROCESSED BY fhe permlt Is for ona hundrad do�lars(5100)or loss.) 1 � � I Cerlify fhof in iha performance of Ihe work for which this AIR HANDLING UNIT,CFM� � ` ����n e . permil is issued,I shall nol employ ony person in any manner � - �� — so os to become sobjetl to ihe Workers'Compensalion Laws._ BOILER,BTU ppvkovat5 onrt INSFECTOk'S SIGNATURE — Date- �applicant � 1 COMPRESSOR,BN �O�OOO ZO OO ROUGH Q. _q� � NOTICE TO APPLICANT: If, after making this Cerfificate of VENTI(AT�ON SYSTEM FINAL ,•"�xemp�ton, you shoold become subjecf to the Workers'_ jompensaiion provisions of ihe Labar Code;you must forth- EyqppRATNE COOiER VALIDATION 'wiih compty wilh such provisions or �his:permil�.shali be deemed revoked. � � � -� � - - FURNACE; FAU_GRAVITY -- � � LICENSED CONTRACTORS DECIARATION � 1 FIOOR . BTU �,O OO I hereby affirm that I am litensed onder provisions of Chopier 9- SUSPENDED � UnliT_ ' HEATER: Wa�� � �'�tommencing with Section 7000)of Division 3 of fhe Business ond Professians Code,and my license is in full force and effecl.-' � � . � � - > 1 �16Z6A � Ltcense t�7omber 3805�3 - �ia Closs C-2� , �+ . . o .� OC . ContmctorR3➢CI30 /�7T� ZIlC�e�e t3-31=89 . � � � � . o p r : t5�25 ' � I am exempt under Set. . .. Plan check fee a B.BP.C.for Ihiz reason' • '0 5 a 2 5� Z - - PERMIT ISSUING FEE S 10 50 _ oo+e: 0920-88 Signoture TOTAL FEE OWNER-BUILDER DECtARATION � � Pv+N CHECK APVLICaNT . � I hereby offirm thaf I am exempt/rom the Conlratfor's License -� , , Law for fhe following reason�Sedion 7031.5,Bosiness and NAME � � - , P^rofeszions Code): - � � . - � ' �''�J I, as owner of�the properfy, or my employees wilh� ADORE55 � � Jwages as their sole mmpensa�ion,will do the work and- ' ��n, TEt.N0. the strotture is not intended or offered for sole(Settion • 7044,Business and Professions Code). . - � � OWniEe �lE Anden Group � ❑ I,os owner of the p�operry,om axdusively mniracting - - wifh licensed mnrroUors to constrod the projeU(Sec- DDRESS 1074 Parkview Drive �2�1 tion 7044,Business and Professions Code). � ' � CONSTRUCTION LENDING AGENCY � � CITY ��• - � - �-�-TEL�Np.� 818-967'95 I hereby offirm thaf Ihere is a conslrodion lending agency for �.'OY1II8 the performance of the work for which Ihis permit is issued� � COMRACioR �NCA� /�R� INC. -� -- - , - (Sec.3097,Civ.C.�. � . . _ _ _..._.._. ... .... __ . .._.. ._. no�aess 1232 W. 9th Street - -- - Lender's Nome �� � � � lende�'s Address � � � � � ��TY �IIC� TE��NO714-981-4801 - - - - - � _ .. _ I cerrif thot I hove read this o timtlon ond staie ihai the sr"TE . 380543 ���� y pp � LICENSE NO. � C1A55 C—ZO ._ .__ .._ _ .._ .."_- __ _. above informalion is correcl.1 agree to comply with all Caonfy � - ---��� " �- -- ordinonces and State lows reloling to building construction, . � � � and hereby auihorize representatives of this Coonty to enter � ' �� � �� � -�� - - ��" ' �� - �---- - � � � ��� � opon t ab ve-mention d property for impettion pvrposes. 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