HomeMy WebLinkAbout1670A ,WORKERs�oMPENSAT�oNOE��ARAT�oN � �APPLICATION FOR PERMIT �
I hereby aff'rcm Ihal I have a terlificate of consent 10 self ,
insore,or a tersiimte of Workers'Compensotion Insumnce, ,aA�a4C HEATING - VENTILATING - AIR CONDITIONING
or a certified topy thereof(Sea 3800,Lab.C.) -�_8l8(REV.10/Bl)�- -
��Y N PwC o5o61�ompanyC'Olden Eagle Ins.
Cerrified copy is hereby furnished. COUNTY OF LOS ANGELES - BUILDING AND SAFETY
O Certified copy�s filed with the covnty building inspeo- FOR APPLICANT TO FILL IN euitDiNG
tion deparfinenl. ' (pRINT OR TVPE ONLY) � ADDRE55 •
oara 5-29-89 APP�i�a��RHIICt10 Air,.Inc. iocnurr Dianond Bar TractN k2582
. NO.- TYPE OF APPLIANCE OR EQUIPMENT FEE
� , CERTIFI COMPEN ATION INSU AN EORKERS' Ceo5555i.IATH �i Job� 876
(Thts s�cl�on naed not be complNed if tho work tnvclvod by ABSORPTION UNIT,BTU orsraia r+o. vaocesseo er I
fhs permif is{or ona hondrod doltors(SI00)or lacs.) � �
� I certify ihat in the performonce of ihe work for which Ihis A�R HANDLING UNIT,CFM � � �0.\O��
- permit is issued,I shall not employ any person In any manner - �
� so as lo become su6ject to the Workers'Compensation Laws. BOILER,BTU AwaOValS DATE INSiEC1OR'S$IGNATURf —
pate -� � epplimnr - ' 1 COMPRESSOR,BTU V���� 10• � ROUGH Z
NOTICE TO APPLICANT: I(,�ailer�making�fhis Certificofe of � � VENTILATIONSYSTEM- FINAL i _ �
� �mption, you should become subject lo Ihe Warkers' . �
pensat�o�provisfons of the Lohor Code,you mus�forth• EypppqqTryE�ppiFR �/ALIDATION
with comply with s�ch provisions or thit permit sholl be
� deemedrevoked. � �� � � - FURNACE: FAU� ¢py IT}�,�
� � LICENSED CONTRACTORS DECLARATION �- . � � FLOOR e7U �vV+vVu 1O. O
I hereby aHirm that I om licensed under provisions of Chapter 9- SU57ENDED � UNiT— - . �
�'(commenctng wilh Section 70W)of Division 3 04 ihe Business� � HEATER: WA��
and Professions Code,and my license is in tull force and eHecL�� � - - - � - �j G 7��A }
a
13 Re�isters @ 1.75 Ea 22. 5 p
Licensa Nvm6er �Rn�h3 i�o.eia::� r—�n � - . _ . - , #• • • • •8 �
• Rancho Air, Inc. 8-31-89 I : :5 a 2 5 0
Contracror Date - - � - � �
� _ v
, s
I am exempt onder Sec. C Jr ci tu
Plan check fee y
8.8P.C.for this reasan' PERMIT ISSUING FEE S 0 9•2 0`8 8 Z
Dale: l�• 0
Signmure TOTAL FEE rj3. 5
- OWNER-BUILDER DECLARATION � � PIAN CNECK AP7LiCANT . � � - "
I hereby affirm�hat I am eaempt from the Conhottor's License . � �
taw for the following reason�Sedion 7031,5,�Business ond NAME . . � - �
Prrrr---o���fessions Code): � - �
Y �, as owner of the property, or my employees with ADDRE55� � • Nt
J wages as Iheir sole compensation,will do Ihe work and CITY TEL.NO.
the shucf�re is no1 Inrended or offered for sale(Settion
7044,Bosiness and Professions Code). . . - - - �
❑ - . OWNER �e }lnden Gro � �
I,as owner of the property,am exclosively contratling �
wBh licensed conirodors to mnsfruU the projetf(Sec- DDRE55 1�7 Parkviex Drive �20�. - �-
� tion 7044,Business and Professions Code).-
CONSTRUCTION IENDING AGENCY -- �-- a7r. . COYlIIB� � TE�•No•$1$�-JE)7-95�i1 � �
I hereby o((irm tho�the�e is a construdlon lending agency for �
Ihe performance of the work for which this permit is issued - � CONTRACiOR jj/�$(,`$O AIR� IRC. - � -� , � � �
(Set.3097.Civ.C.). � . . . � - ' --' - -. . .
� � � ADDRE55 1Z32.W. 9t.Yl St.T20t � _ . . .� '. _ ._ ._ . . . . �
lender's Name �
aTr 1���$— upland_��.rro.71b-981-1+801 _ _ __
Lendei s Address � �� �� �
STATE p UC.
I certify that I have reod this applicotian ond state that the LICENSE NO. 3UOrJ�3 CLa55� C-2� . . .._.... ..____ . .. . . ._�.
above information is correct.I agree m comply with all County , _
ordinantes and Stote lows relating to building canshuction, .
ond hereby ou�horize representatives of this Coonty ro eMer �� � � - - . - -
upon� obove-meniioned properry for inspection porposes, SEE REVERSE FOR EXPLANATORY LANGUAGE
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