HomeMy WebLinkAbout1676A (10) 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. SEE REVERSE FOR EXPLANATORY LANGUAGE
� Ia�a.�Co �ay��
Signaeura of Applicanl or Agent �Da�e . . . .. . . . . �. -- --.. - .- . ... ._.. _._. ...__ _._'.-
------ -- . -- --- -- ._......_..__
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