HomeMy WebLinkAbout1668A (10) 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 .
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