HomeMy WebLinkAbout1675A (10) .WORKERS'COMPENSATIONDECLARATION � APP�,ICATION FOR PERMIT �
I hereby affirm that I have o certificote of consent to self .
insu�e,or a cenificata of Workers'Compensarion Insurance,. HEATING - VENTILATING - AIR CONDITIONING
or o certified copy ihereof(Sec.3800,Lab.C.) 76A364C �
.. .� CE.818(REV.10/81) - � -
� Policy No����ompony � .
❑ CerriFied copy is hereby fum�shed. COUNTY OF LOS ANGELES=- BUILDING AND SAFETY
�g Certified copy is iiled with the coun�y building inspeo- FOR APPLICANT TO FILL IN BUi��iNc
� tion deporfinent. � � � � � A�DRESS 719 P�tera Drive
., �PRINT OR NPE ONIY)
oo+e 5-2�89 qpplican�R3IICh0 Air, Inc. �«^��TMDiamoad Bar Tract# 42582
� NO. � NPE OF APPLIANCE OR E�UIPMENT . FEE
. ' CERTIFICATE OF EXEMPTION FROM WORKERS'. CRO55 57.I+�YrN 9 Job# 876
COMPENSAiION INSURANCE � �
(Thb�s�etlon nsed nol ba complNed ff Ihs work fnrelved 6y ABSORPTION UNR�BTU DISTRICT NO. PROCESSED BY
�the parmff is fDr one hundred dollars(f100)or less.) qIR HANDIING UNIT,CFM
� I tertify thol fn the performance of the work for which this � �p\�r1 �
- permit is issued,I shall not employ any person in any�manner gp��ER,BTU
so os to hecome subjed to the Warkers'CORIPC11SOfi0I1 L�wS. APFROVAlS DAiE INSVEROk'S S�GNAiVRE —
1 COMPRESSOR,BTU 60�000 I,O OO ROUGH
Dete � �Applicant .
NOTICE TO APPLICANT: If, af�er making �his Certifimre of VeMitaTiON SVSiEM FINAL
� �ption, you should become subjeU 10 the Workers' . � � � r
pensation provisions of Ihe Labor Code,you must forth- EVAppRATIVE COOIER VALIDATION
wrth comply with such provisions or this permit-shall be
�deemed revoked. �� � � -� �� �- FLOOR CE: FA�➢DL__GRe'I�O�_ lo 00
LICENSED CONTRACTORS DECLARATION - � .LU �
I heieby affirm thot I am Iicensed under provisions of Chapter 9 . - SUSPENDED UNIT_ -
�(mmmencing witb Section 7000)of Division 3 of the 8usiness HEAifR: wA��
. and Professions Code,and my litense is in ful I force and eHecL � � ��- � � d ,
13 Re isters @ 1.7 Ea 22 p
Ucense Number,3$OS�� �iu Class�—�g , �� 5 7 5� U
�
CoNraclorRanrhn Air Tnrpnte $—�j,—$Q_ . � - #� � • • e 8 �
� ❑ 1 am exempt under Sec. ' � _- � �� •��2 Jr w�
Plan check fee
8.8P.C.for�his reoson' - �
PERMIT ISSUING PEE S 10 50 e • +5 3 2 5� ?
Oate:
Signatore TOTAL FEE 'z 0 9,2 0—8 8
OWNER-BUILDER DECLARATION PLAN CHFCK AFPLICANT � � .
I here6y aiGrm thot I am ezempt from the Contrac�or's License� - � i
taw for the following reason(Sectlon 7031.5,Business and NAME � . �
- ---�Professions[ode):� � - - _ ' �
�� � I, as owner of the property, or my employees wilh ADDRE55 - - - � �� - __
--wages as Iheir sola compensation,will do the work and �� . , .
the s�ructure is not intended or offered for sale(Section CITV TEL.NO.
� 7044,Bosiness and Professions Code). _ � � � � ��
OWNER rjr�e Anden Gr ll
❑ I,os owner of the property,am exclusively contracting 1. �
wilh licen5ed cONmtlors�o tonihuct fhe projed(Seo-� D�RESS 107�+ P82'�V1CH DT1YC �2�1 �
� tion 7044,Business and Professions Code). �� - . .
GONSTRUCTION LENDING AGENCY � - - Ciry. Cppy�g� - . ' � h�,NO.slB_967_9541
I hereby affirm that thera is a constructionlending agency for � �
the performance of the work for whith this permit is issued �-� �prvTRACiOR ��0 � IAC. �
(Sec.3097,Civ.C.). � � -�- - - .- �. . . ...-. .
,...,,.. ... . -_ .. _ . ..
nooaess. 1232 W. 9th Street =-: . _. ...
Lender's Name
cirv . Upland rei.No.714-981-480
Lender's Address
. - STATE LIC. . '
� I certify that I have read ihis applicotion and sfa�e rha�rhe uc�Nse No. 3805�+3 cwss C-20 - �� � -�. -� � � . �-_ . . . . .... _ .
.obove information is mrrect.I agree ro tomply with all Counry �
ordinances and Stata laws rela�ing to building construction, . � , � . _ �
and hereby aolhorize representatives oYihis County to enter � . � - � -� - � �� '� -- ' - - - �
upon t e a ove-mentiorgd properry for inspection pvrpases. 5EE REVERSE FOR EXPLANATORY LANGUAGE . ...
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