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HomeMy WebLinkAbout1674A (26) WORKERS'COMPENSATIONDECLARATION �' . APPLICATION FOR PERMIT � I hereby affirm ihot I have o certiiimte of tonsenl�o self � - insare,or a certifico�e of wo�keri Compensation Insvrance,. �aA��, HEATING - VENTILATING - AIR CONDITIONING tti or o terti(ied copy ther'eof(Set.3800,1a6:C.J -CE•eie�RFV,l0iei)� � - PFIC 05061� Golden F�gle Ins. P❑olicy Fto. ompony COUNTY OF LOS ANGELES - - - BUILDING ANO SAFETY Cerlified copy is hereby fumished. a Ceriified copy is filed wi�h the couMy building inspeo- FOR APPLICANT TO FILL IN BUILDING fion deporiment. .400RE55 (PRIM OR NFE ONLY) � � � pa��-29—f19 APAlita�ancho Air, Inc. ���in' Diamond Bar Tract# k2582 . Np. iYPE OF APPt1ANCE OR E�UIPMEM FEE CERTIFICAOTENVENSATIONOINSU AN EORKERS', � � - - CRO55 Si,LOTN B JObJI BT6 (Thls s�ction naod no!bo compioted if fho work Involved by F+BSORPfION UNIt,BTU OiSiRiCI NO. PROCESSED BY 1ha pnmlf fs(or ond hvndred dollon(SI00)er le6t.) qIR HANDUNG UNIT,CFM - L� I certify thot In the performonce of the work for which this . ��\0fL� - . permit is issued,I shall not employ ony person(n any manner BOitER,BTU so os to become subjetl to the Workers'Compensalion laws. . nvraovnis � onr[ INSGECiOR'S SIGNATVRE _ Dcte �- Applicdnt �' COMPRESSOR,BTU 60+��� �-0•�� ROUGH L�' r NOTICE TO APPLICANT: If,�af�er making this�Certifim�e af � VENTiWTiON SYSTFN� FINAI .Z : �mption, yov should become subjett 10 the Worken'. . �pensation provisions of the lobor Code,yoo must forth• ¢vqppRanvE COOteR �VAL D TION wilh mmply wifh such provisions or this permii sholl be deemed revoked.� � � � 1 FURNACE:. FAU�GRAfLI'Y��_ lO.o0 � �LICENSED CONTRACTORS DECLARATION � FtOOR BTU 1UU � 'I hereby otfirm�ho1 I am�icensed under provisians of Chopter 9 HEATER: SU57ENDED UNIT_ '(commencing with Section 7000)of Division 3 of the Business � WALL � and Rofessions Code,ond my litense is in full force and effecL � . . . , y' 13 Registers @ 1.75 � 22.7 0 license Number 3$n�h3 - � i��.aaSsV—�p - . ._ . . ' � � -�t 6Z4A � ; ControctorRanrhn dir� Tnr_[iate �4l—$Q . . - . .- . ' #���� . •8 O V ❑�-I am exempt onder Sea � . . . . � I ��J�2 J� W Plan cFieck fee �- N B.BP.C.for this reason pERM1T ISSUING PEE$ + ` �5�2 5 c=.� Z Date: TOTAL FEE 0 9,2 0—E 8 Signatura" 53. 5 OWNER-BUItOER DECtARATION . rtAN CHECK AvauCnntT � I hereby affirm that I am exempt from the CoNrotlor's Licensa � , � Low for the following reason(Section 7031�.5, 8usine:s and NAME� � . . . �- Pf�roIfessions Code): � � �� ' - . � `t I, as�owner of the property,�or my employees with ADORE55 � . - . � . Jwages as�heir sole wmpensafion,will do�he work and - [Itt� TEL NO. - the structuie is not intended or aifered for sale(Settion 7044,Business and Professions Code). -_. � - " own�ea �e Anden Grou ❑ I,as owner of tha property,am exdusively mNracting wilh licensed tonlrattors to construct the projeU(Seo- MA�� �]_07�1 P&P�CY1E{P Di'ive �201 ' � tion 7044,Business and Professions Code). � � A�DRESS CONSTRUCTION LENDING AGENCY - �- CRV �COV1D8� � � - TE�•N�$1$-967-9rj11�, 1 here6y affirm ihat there is a con:truction lending agency for � . the performonce oT the work for which thia permit is issued CONTRACTOR� �A�O AIR IlPC. � (Sea 3097.Civ.C.). � � � � - - � - -... --. . .. . . , . . . ADDRESS . . .1'�3Z W.-9t}3 aS�7T2@�) ._ .. . _ ' _. .. .. . . _.- .�.� :.. . -� . Lender's Name � arv. Upland Te�.No.714-981-4801 _ - Lender's Address 1 cenif thm I have read this a lication and smte that the SiAiE � l�C. y pp UCENSENO. 38�rj�13 - QA55 �C-2� - -. . . . . . . . . . . _ .. above informotion is correct.I agree to comply wilh all Co�nty ordinonces and Sioie laws reiaiing to 6uilding construction, and here6y authorize�epresenfatives of ihis Counfy to enter � ��-� �� � . . �- ��-� -� � - � �-��� - - � --��-- upon� e o ove-menti ned property for inspeuion purposes. ' � SEE REVERSE FOR EXPLANATORY LANGUAGE �'�?iia.�.co �ay�� _ _ _ _ _ _ _ Sgn6ture af Applicant or Agent Doie . - . � � � . ' - - ---... -. . : . . -. - . . __; ------.- _ ._. �, ..._.. . f I � , � � i ; ; _ � - - � . � � �- ; . � `; , , � . ! � - i ` . � ��, ,= � � i m ' ! .- � ^ c_ • . Of� �✓l . � � ___ .. � . . � ' Z ' . I. .. . 1 � O �� '' - ' ��` '� . . y , . t .._ . i - , t . . �_ ,.. i i i.... �:, . _.. :_ ' � - - , G: ; - , ' I ' S �- .' .� ' • . . ,..-I ' -..+ _„ _ . 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