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HomeMy WebLinkAbout1668A WORKERS'COMPENSATION�ECLARATION � APP`ICATION FOR PERMIT � I hereby affirm that I hove a certifitate of consent�o self � � insore,or a certificate of Workers'Compensation Insurance, �bA��� HEATING - VENTILATING - AIR CONDITIONING �or a ce�lHted copy thereof(Set.3600,'lob.C.) — CE•818(REV.10/81) - � - � - ' - POOIityNo.�wr n�Q�mpany_(=�+lAcn Ti�ole Tng�, . . Certified topy�s hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY XaCerrified copy is filed wi�h the tounry building inspee- FOR APPLICANT TO FILL IN 6Ui�owG 747 E �fion departmenl. � ADDRESS ����'ive Pantera Dri � � (PRINT OR TYPE ONLY) Date 5-29-89 �.. ApPi��a�,Rancho Air,�Inc.-- iocnim Diamond Bar .Tract# 42582 NO.� ttPE OF APPl1ANCE OR EOUIPMENT � FEE CERTIFICAOMPENSA ION'�INSURANCEaRKERS' CROSSSST.I�# 2 Job# 876 (This sacfion noad no1 ba complrT�d if ihs werk Involved by ABSORPTION UNIT�BTV DISiRICT NO. VBOCESSED BV tha permH I�Ior ona hundred dollor�(t100)or lass.) AIR HANDUNG UNIT,�FM `1 / J I cenify thot in ihe performanca of the work for which ihis l�V �0.1pn� _ "permit is issued,I shall not employ any person in ony manner so as ro become subject ra the Workers'Compensation Laws.._ BOILER,BTU APPROVqLS DATE INSFECTOR'S SIGNATURE — Dote app�i�a�t - COMPRESSOR,BN �O�OOO .O ROUGH _NOTICE TO APPLICANT: If, af�er making this Certi(imte of VENTILATIONSYSTFA1 FINAL Z� �J�mption, you shou�d become subject to the�Workers: .. pensation provisions of�he Lo6or Code,you�most forth- EvacORnnveCOO�ER VAIIDATION -� with mmply�with such provlsions��or this permit shcll be -� deemed revoked. � � .�� - �- � � - FURNACE: FAU� IT � - � � . ' LICENSE�WNTRACTORS DECIARATION� �- FLOOa BTU ���� SO.00 � I hereby affirm ihat I am licensed under prpvisions of Chapter 9 SUSPENDED UNIT_ - HEATER: WA0. '� .''(commencing with SeUion 7000)of Division 3 of the Business � � G G S A � and Professions Code,ond my license is ia full force and effect. �13 Registers @ 1.75 F:S 22. �� � • • *8 �' 380543 . C-20 0 License Number lic.Class � , � � - � � � - ` � e s 5 3 2 5 aC ConiracrorRAN('.An ATR� TAC_nate$—�c$� _ � a . . .��zs�, I am exempl under Sec. w Plan check fee 0 9 2 O—8 8 y 8.8P.C.for�his reason' PERMIT ISSUING FEE S � Date: Sgnorure TOTAL FEB rj3. �f � OWNER-BIJILDER DECLARATION � - MnN CHECK APFufANt , , I hereby aifirm Ihat I om exempt from the Contraclor i License _ , � law for the followinq reason(Secfion 7091.5,Business and NAME � . Prrr���rofessions Code): � - � ' � � �1 I,as owner of the property, or my employees with /+DDRESS - J wages os their sole compensation,will do ihe wo�k ond the srruttwe is not imended or oifered fo�sale(Secfion CrtY TEL No. 7044,Business and Professions Code). � . - � � OWNER rjrhe �IIdeII (i`Y•011 ❑ I,os owner of the properry,am exclusively contracling wilh licensed cOntratfors to mnstrocf the project(Sec- DORESS lo7k ParLv3e� DI14Q �201 � �tion 7044,Business and Rofessions Code). CONSTRIICTION LENDING AGENCY �-� dTv. -COV1I18� T���N��8j8—�J67-954]_ I hereby affirm thot there is a construction lending agency for � Iha performance of the work for which this permit is Issued � � GOMRACTOR ��ftC�IO AIR INC. , (Sec.3097,Civ.C.). � � - . _ . _.. .__ ..._._. _.. _. � - - - � AD�RE55 - . ....... �.__ ... �.. � ' '..' � ... . . . . _ lender's Nama . an �p�d re�.No.714-981-4801 Lender's Address - - - � � �� - � - -�� ' � STATE LIC. I cehify thof I have read this application and stata thal the uc�r,se No. 3805�3 CtA55 C-2�. � . .. �. . _ _ _ _ .. . . . �. . ,.. obove Informption is correct.I agree to tomply with all County ordinances and S�ate laws relating to building conslruction, � , ` and hereby outhorfze representalives of this CovMy to enter ; . . - �� � � -�� � - - � � �"�- �- - �" "- � - vpon he ppove-mentio�rry for inspedion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE . 1Jn n o� � r8 I L.lL( Signc�ure of�Applimn�or Agen� �Dafa . . .. . .. . ".- . , . .. _- . . . _. . . . � _ -- �� � ` � �, � � � � � ,. . . .. �' � ; , , ` _ �t . .. i - , , ; `+ ": , t _ ,y -- , .+ S- ^ . ` �� � , , Z '��- •, i `� - -- '•,^. � . a `-;t , m �- . ' �1 - � _. � `1 '.1.-- , , _ . �j ,� '� '. ' �, �•.���,.. �� .�. . . N . 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