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HomeMy WebLinkAbout1674A (25) .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 .' ' -. ' . . . . . ...-. .. .... . . .�. .-. . .-. .. . . .. _ , � . ;__� -. s � ` , � ', - � ' �,' E �'y ' ' '_1 �,`_�. - ', j� •'t _ :t '":: . , . " , t ' _ t .- �.. � . , . . - i �. . . -�,t� �. �. � � ,��' '�; ' , . .�� , . ', . . � m '. ,f '}r- F , ,"�. ' � , . � c_ . p� . ..__. ,S,. , � ' • ; " a `�, ' , m . _ ' . v� , . _ .. � _ " � `. _ '. _ , � � -- � ' • _t • _ _ � � - . n , ',' '+' ; , , , . . 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