HomeMy WebLinkAbout1674A .WORKERs�oMPENSAT�oNOE��RAT�aN �. qpp��CATION FOR PERMIT � �
I hereby affirm thol I have a tertificote of tonsent to self � .
inwre,ora cerrificote of Workars'Compensmion lmorance,. - HEATING - VENTILATING - AIR CONDITIONING
or a tertified mpy thereot($ec.3800,Lob:C.) ���� _
E'WC 05061.� Golden Eagle Ins. �'sieleev.iaiai� � -
P❑olicy No. ompony . . . . . .
Certified copy is hereby furnished. COUNTY OF LOS ANGEIES BUILDING AND SAFETY
� Cerfified copy is filed wilh the couniy 6uilding inspeo- FOR APPLICANT TO FILL IN � eunotNG
fion deportmenL � ADDRE55
� (PRIM OR NPE ONLY) �
om�—�9-89 APPlicdr��cho Air, Inc: ����n Diamond Bar '1`ract� k2582
. . NO. TYPE OF APPLIANGE OR EOUIPMENi FEE
CERTIFICA7E OF EXEMPTION FROM WORKERS' � � - NEAREST �
COMPENSATIONWSURANCE ' ceo5s57.�N 8 JObN S7C
�(Thit sodlon naod not 6o complafed ff fhe woik(nvolved by ABSORPTION UNIT,BTU pISIRICi NO. PRpCESSED BV
tho parmft is for one h�ndred dollors(SI00)or lass.) �� � \
I certify that In the performance of the work for which this - AtR HAN�LING UNIT,CFM - � a��
_ permit iz issued,I shall not employ any person in any manner BORER,BTU —
so os fo betome subjett to ihe Workers'Compensalion laws. nvaaovnts ont¢ WS�ECTOR'S$IGNATURE
. �- COMPRESSOR,BTV � 60�000 ZO.00 ROUGH l� �
Date .. APPlicanf
NOTICE.TO APPLICANT: If, after making this Cerlifico�e of VENTIlAT10N SYSTEM F�NA� 'l
:��mp�ion, you should.become subject to the Workers'.. .
pensotion provisions-of ihe Lobor Code,you mus�forih- EVAPORATIVE COOIER VAL D TION
-with comply with such provisions or this permit shall be
deemed revoked.� - -� � - ' � 1 FURNACE: .FAU�L_GRAXiTv�— lO.Qo ,
. � �I�CENSED CONTRACTORS DECIARATION� - FLOOR BN 1UlJ �
�I heie6y affirm thoi I om li�ensed under provisions of Chapier 9 � HEAiER: SUSPENDED UNiT_ - ,
�(commencing wilh Section 7000)of Divisfon 3 of the Business ' � WA« � .
ond P�ofessions Code,and my license is in full force and effect. - - - -�� . . y'
13 Registers @ 1.75 Ea 22.7 p
License Number ZA(1521�„T?lic.Class (,.'—'�Q �� - . - � , �1 6 7.4 A V
CC
.. ContradorRanchn Ai r� Tnr Jiote$—'�l—$,Q_ _ . ' ' #•.+� �• •8 O
.❑� � . . � . . . . .._ . . . U
�I am exempt�nder Set. � �a 5 3 2 5 a
Plan cHeck fee
B.BP.C.for this reason' pERMIT ISSUING FEE; °` �5�2 5 c=.• Z
10
Dote: TOTAL FEE 53. 5 0 9,2 0—�8
$ignalure -
OWNER-BUILOER DECLARATION PLAN CHECK APftICAM , .
I hereby affirm ihal I om exempt from the Contmctor's License - ., ,
Law for the following reason(Section 7031.5,Business and NAME� � . - .
, --Pf�"'o1(essions Code)r� �� . - �, - , _ . _ , _ _ , _ ._
`( I, os�owner oi the property, or my employees wifh AD�RESS . � . �
Jwoges as their sale mmpensotion,will do fhe wo�k and ��TY TEL NO.
the structure is not intended or oifered for sale(Secfion
7044,Business ond Professions Code). , ,. � '
❑ . . . . _ . . � . OWNER �10�AII(�0II CrP011 '
I,as owner of tha propery,am exdusively toniratting_ Mnil �� -� - ��
with IiCEnsed Conlraclors to consiru[t Ihe pro�ed�Sec- A�DRESS 107�+ Parkvie�r Drive �2��- '
tion 7044,Business and Professions CodeJ. � �
CONSTRUCTION IEN�ING AGENCY� �- UTY �Cpyjp�� r��.Nog�8-967-9541
I hereby affirm that ihere is a construction lending agency for ,
the performante of the work for which rhis permit is issued � � CONTRaCiOR� j�]�j�gO AIR II'TC. �
(Sec.3097.Civ.C.J. . . . ..... .._ ..... .. .. . _.... . _- - .
nooeess 1232 W. 9th Street . . _�. '.. . _..
lender's Name �
lender's Addreu � - - ��TM Uplsnd - .TEi.No.71�+-981-4801 - �- �
STATE p LIC.
I certify that I have read fhii application ond stote�thot the UCENSENO. 3UOrJ43- �- � CLA55�-�C—PO .. .. . _ .. . . . _.. ._.. ....
above informotion Is correcl.I agree to compiy with all County
o�dinantes and Sta�e laws relating�o building mnstruttion, . _ .
and hereby authorize represenlalives of ihis Cwnry to enler � - - � � � � - -- �� � � � �
upan�t e a ove•menti ned property for inspecrion purposes. '� � SEE REVERSE FOR EXPLANATORY LANGUAGE . � .
� �Y,'�lll./�,co �a%� _- _ _ _
Signoture of Appli<ont or Agent Date .' ' -. ' . . . . . ...-. .. .... . . .�. .-. . .-. .. . . ..
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