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HomeMy WebLinkAbout1669A .WORKERS•�oMPENSAT�oNOE��,RAT�aN - APPLICATION FOR PERMIT � I herehy affhm ihat I have a terfiflcota af content fo self � . tnsure,or a certifmte of Workers'Compensation�n:�.on�e, - �bA��� HEATING - VENTILATING - AIR CONDITIONING ts or a cerrified copy thereof(Sec.3600,Lab.C.) - CE-BIB�REV.-10/HI) � � - � � - - Ocy N PWC OSOEiI�-ompany�olden Eagle Ins. Certitied copy is hereby furnished. COUNTY Of LO$ANGELE$ BUIIDING AND SAFETY X Certified mpy is filed wiih the county buildin9 inspeo � ❑ . FOR APPLICANT TO FILL IN eui�owc fion depercf1inent ` � � ADDRESS !� pantera Drive 5—Z9—S7 R3IICH0 Aj.Y'� IIIC. (�RIM OR TYPE ONLV) oore Applicont iocnutr Diamond Bar TractN 42582 NO. TYPE OF APMIANCE OR EQUIPMENT -��� FEE CERTIFICATE OF EXEMPTION FROM WORKERS' - NEAREST L�� 3 JobN 876 - COMPENSATION INSURANCE CROSS Si. -�(Thfs soction nood nof bo complatad if the work tnvolved 6y ABSORPTION UNIT,BTU O�S�aiCl NO. vROCESSED BY The pe�It Is for on P hundred dollars(5700)or lesi.) � qIR HANDLING UNIT,CFM 1 v� rn 0.\�n � I certif that in the erformance of the work for whith this - �permit is issued,I shall not emplay any person fa any monner gOILER,BTU so as to become subject to the Worken'Compensation Lows. . nvva0vnts �nte INSPFCTOR'S SIGNATURE 1 COMCRE$$OR,BTU GO.00O �O OO ROUGH ��_� Data epplicant ' . NOTICE TO APPLICANT: If, aiter makfng this�Cer�iiimta of vENTRA7iON SYSiEM FINAL ' �7L� �mption, you shovld 6ecome subjed to the Workers: _ � �' pensation provisions of�he LnF+or C«fe,you mvsl forth- EVAPORnTNE COOIER VALIDATION � with comply wfth suth provisions o� this permiY shall ba � � �deemed revoked �'� � � � FURNAGE: FA���c�t VI7y - -- � LICENSED CONTRACTOR$DECLARATION� 1 FLooR � eru lU�,UO�— lO OO ' 1 hereby affirm thot I am licensed under provislons of Chopter 9 HEATER: SUSPENDED UNIi_ . . . '(tommenting with Section 7000]of Division 3 of the Business �'A« � } . and Professions Code,and my license is in full force a�d effect." - - � - - a � 380543 ii�.aa:5 C-20 1 Re isters @ l. Ea 22 75 p License Number � -- - - � -�� , V �1669A � ControUor RSIICt10 A1T.'Inc po,e 8-3�-�89 _ . . . . #i � • . •8 O � � I om exempt onder Sec. � .. w Plan check fee I •�5 3.2 5 N B.BP.C.(or this�eason� � � PERMIT ISSUING FEE s 10 50 • o a 5 a 2 5� � Date; Signoture - TOTAL FEE 53 25 p g,p p—g g OWNER-BUILDER DECLARATION �- atnN CNECK AaruG4NT � . . I hereby af(irm Ihat I om exempf from the Controctor's License � � - ► . Law for ihe following reoson(Section 7031.5, Bvsiness and N.4ME � . � P�ro-1fessions Code): � ' �� - - . `! I, as owner of the property, oi my employees wifh ADDRE55 Jwages as their sole tompensatian,will do tha work ond the strucfine is no1 intended or offered fOr sole($ettion CITY � TEt.NO. 7044,Business ond Professions Code).. .;,_. � - � - � � � � OWMER rj�e p,nden Grou �� � ❑ I,as owner oF the property,am exclusively conlrading with licensed[ontrocto�s to consfruct the projecf(Sec- DDRESS 107k Parkview�Drive �2��. �- � ' - �ion 7044.Business ond Professions Code). � - � CONSTRUCTION LENDING AGENCY � - - Cltt �� COV�IIB� , � -TE��N��� SZH-96�T-9S� � I hereby aNirm thar there is a construc�ion lending ogency for � � the performance of the work far wh�ch fhis permi�i4 iSSUEcI � CONTRACfOR �g�0 �R INC. � � � � ,_ (Sec 3097,Civ.C.). � � .- _ . _.. ... ---., ....__ . . ._-- � � ADDRESS . . . _�' . ._ . _. ..:- � � �.C�.� .:_- .__. . Lender's Name StYC.'Ct �-� � � �ender's nddress ��TY Upland �ei.No.714-9$1-4801 _. _ _ . I certify that I have read this opplicotion and slale that the._ �C�NSENO.� 3SOS�3- CLASS C-2� . - obove informalion is cor�ect.1 aqree�o comply with ail Coumy . �.. ._.. - - -�- �-.. � .... .�..... ... ... . . ordinances and Staie laws relating to boilding construdion, - - � and hereby autho�ize representatives of�this County to enter � ' �. � - '�- ' . ' " -�" � " ' --� � --�- " � -�` - upon e ove•mentioned properly for inspedion purposes. ! _SEE REVERSE FOR EXPIANATORY LANGUAGE , �.d,�o g aU�R ; -_ . - Signa�ure of�Applimni or Agent � Dare - - � -- - . . . �. . .. -._. .. " -- .. . .. ... .. ..' ._.. _ .,��t _ —, . � �, , . � . � � �, � 1, ^� � 1 's + '` , ', � :� . � '� ��'" ��t , t . . _..._ ,,, � , . , _ . ,�� t ���, � '' y - �; '. - � '� .- .- '� i, , ' � . '�'• -. . . 'i , . . , _ - 1 �t ,: _���,� � �� _� `. _ : ,;�:._ Z ,..- �� �' � � . � , �" � 'r � � 5 �� . , ,( +, . � ' , • , . ' ' . O ' ` � .' . � '. � �•_..-;,.. . �` '1'` �. , 1 1 . 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