HomeMy WebLinkAbout1669A (10) .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 - - � -- - . . . �. . .. -._. .. " -- .. . .. ... .. ..' ._..
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