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HomeMy WebLinkAbout1673A (10) .WORKERS'COMPENSATIONDECLARATION APP�,'CATION �FOR PERMIT � I hereby afFirm that I have a cerlificale of consent to self � insure,or a cer�ificate of Workers'Compensation Insurance, �bA��� HEATING - VENTILATING - AIR CONDITIONING `or a certified topy theraof(Sec.3800,lab.C.J CE-818(REV:IOrelj-- �� � � � - - -� � � PHC 05061�? Golden Ea.�le Ins. P❑ol�cy No. ompany COUNTY OF LOS ANGELES BUILDING AND SAFETY CertiFied copy is hereby fumished. . 7� Certified copy is filed with the coonry building inspet- FOR APPLICANT TO FILL�N euaowG fion depa�tmenl. - (PRMT OR NPE ONLY) � ADDRESS pa+B 5-29-89 APP�i�a��RSI1C}l0 Air, Inc. �ocu,ur Diamond Bar Tract# 42582 NO. TYPE OF APPLIANGE OR EQUIPMENT � FEE CERTIFICATE OF EXEMPTIOtJ FROM WORKERS' NEAREST ' � � COMPENSATION INSURANCE - - - Ce055 S7. �1'II 7 aob#�876 . (Thl�sodton n�ed not be cainplot�d It tha work fnvolvad by�- /BSOaPTION UNiT,BtU DISTRICT Np. VROCESSED BY - the parmH t�for one hvndrod dollars(S1D0)or lass.) . I cerfify Ihat in Iha performonce of ihe work for which ihis A�R HANDLING UNIT.CFM �O �M 0.�n� permit is issued,I sholl not employ ony person in ony monner i , ` so os lo become sub�eU lo the Workers'Compensalion Laws. BO�IER�BTU APGROVAlS DATE INSPECTOR'S 51GNATVRE — 2 COMPRESSOR,BTU 36�Q�� � 20 00 ROUGH Date Applicant � . Zdl � NOTICE TO APPLICANT: If,�oher moking fhis Certificate of , VENTILATION SYSTEM FINAL Z. -��emption, yov should become subject to the Workers'_ ' . mpensalion provisions of 1he labor Code,you must forth- EVAPORATNE COOIER VALIDATION � 'with comp�y wlih such provisions or th(s�perml��sholl be deemed revoked. �� -� �� �'� ' ��� FURNACE: FAU�Opq VI - . . LICENSED CONTRACTORS DECIARATION - 2 FLOOR gTU oU+��— 2O OO � I hereby affirm thot I am licensed onde�provisions of Chepfer9 HEATER: WA�NDED UNIT_ �1 6 Z 3 A '(commenting wi�h Setlion 7000)of�ivision 3 of fhe Business and Professions Code,ond my litense is in full force and eHecf. , � } 15 Registers @ 1.75 Ea. 26 25 «•' • • •a a' O License Nomber�Rn�+�� - Lia Class C-20 - " . '" � � � � � � - , � � y 7 Q 7 Jr V � ContracrorRanvhn Air Tnrnate..$-��-$,�_" � . � - . � rx O as . . • •� /C1rIJc F- 'I am�exemp�under Sea a Plan check fee 0 9.2 0—8 8 6.8P.C.for this reeson� � �� y oa�e: PERMIT ISSUING FEE S lQ � $ignature TOTAL FEE 76. 5 � OWNER-BU4DER OECLARATION , PLAN GHECK APPL�CANT , , I hereby ofliim thot I om ezempt from Ihe Coniracfor i license , , Low far the following reason(Section 7031.5,8usiness and NAME � . . . ,-Professions Code): ` - � - - � � I, os owner af the property, or my employees wilh /+DDRE55 wages as lheir sole compensation,will do ihe work and Cltt � - TEI.NO. � � the structvre is not intended or of(ered for sale(Sedion � 70-04,Business and Professions Code). � - � OWNER �e Anden Grou � . ❑ I,as owner of the properiy,am exclusively contracting . with licensed contratlors io construtt ihe project(Sec-- ODeE55��'�7 P�'�e�r Drive�N201��� " -- - tion 7044,Bvsiness ond Piofesslons Code). � CONSTRUCTION IENDWG AGENCY orr � Covina; � re�.No. $1$-9(7-g5�+1 1 hereby offirm�hat there is a conshuction lending agency for � the performance of the work for which this perm�r is issved-. �ONiRncroe j�{g�j0 /1IR� INC.�� � � �� � (Sec.3097,Civ.C.). . � . � . ._ . ... _ _. _ . _. . -{ . - - .' _.+' � � � ADDRE55 �� �.P Z W. tH St2'C t � . . .. . . .- . _ .. _. - . .. .. _ . ..... ... lender's Name cm Upland Tei.No.714-981—�+$Ol . _ _ _ _ _ lender's Address I certiFy thai I have read this applicotion and s�ofe 1ho1 ihe. LI�ENSE NO. � 3�OS�3 �ttASS C'20 . .. . . . obove intormotion is correct.I agree to comply with all Coonty � . . � ordinances and Stme laws relming to building tonstruttion, , �, . � � - and hereby authorize represemaiives of this Coonry fo enfei �� �� � ��� � -- � � � �� - -��� �� � - - `-��-����� � . opon th ob �e-mennoned propeny for i�spedfon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE _ � �a a.� �--��' _-._ - _ _ Signotore of�AppGcan�or Agem � .. Do�e - . - � -- . . .. � . . . . . . . _ .. .. . ... 'l �, . • ..�,,.�.,`� `1 - � ,`. ' ',` \ ` _ � `. . �' 1 -� ,� . � . ` 1 ` � . .. � , . ``^ `. `.'. . . . . .- .. ' . _ � '�. - �l� . t� �-. . � .. ,. � ��a ' . . . .. , �� ' . � �� , �� • . . ,``r. .� � ., . .. , , - . ' _ . ... ' ' ` ,.; �, . � '\�� `,� '�',+ !- �_ �,- � ' . ' . V� ` �, � + .�. ff� .. .�,. , 1" ' , ..` ., ' �5 ,. N R.. ' ..� ;" . � . � �` . � . i` , - � .. _' . Y _ • �` � . � " l, �� ; 4', + � w . , , C ' . . 'r, •�1,} � � ,.` .. 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