HomeMy WebLinkAbout1667ACOMPENSATION
DECTION
Worm
APPLICATION
FOR PERMIT
that Ihove cafe of corse
I hereby affirm that I hove a certificate of consent to self
;insure, or a certificate of Workers' Compensation Insurance,-
- HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3810, Lob. C.)
76A364C
Policy No. PUC 0 063&mpony Golden Eagle Ins.
CE -818 (REV. 10/8I) -
❑ Certified copy is hereby furnished.
COUNTY OF LOS ANGELES
BUILDING AND SAFETY
Certified copy is filed with the county building inspec-
FOR APPLICANT TO FILL IN
BUILDING
tion department,
(PRINT OR TYPE ONLY)
ADDRESS 751 Pantira Drivi,
Date 5-29-89 ApplicantRancho Air, Inc.
LOCALITY Diamond Bar Tract# 42582
CERTIFICATE OF EXEMPTION FROM WORKERS'
. NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST -
CROSS ST. Lot# 1 Job# 876
COMPENSATION INSURANCE
(This section need not be completed if the work Involved by
ABSORPTION UNIT, BTU
DISTRICT NO. PROCESSED BY
the permit is For one hundred dollars ($100) or lass.)
t
I certify that in the performance of the work for which this
AIR HANDLING UNIT, CFM
D CAO 'e
permit is issued, I shall not employ any person in any manner
-
so as to become subject to the Workers' Compensation Laws.
BOILER, BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
_
�- COMPRESSOR, BTU 60+000 1(-00
ROUGH0, ...
Date Applicant
NOTICE ,TO APPLICANT: If, offer making this Certificate of
VENTILATION SYSTEM
FINAL L- _
' mption, you should become subject to the Workers'
i, pensation provisions of the Labor Code, you must forth-
EVAPORATIVE COOLER
VALIDATION
with comply with such provisions or this permit shall be
deemed revoked.- - - - -
1 FURNACE: FAU.7�_GROYJTYOQO_ lO OO
1I VVUU
LICENSED CONTRACTORS DECLARATION
FLOOR BTU
- I hereby affirm that I am licensed under provisions of Chapter 9
HEATER: SUSPENDED _ UNIT_ -
"(commencing with Section 7000) of Division 3 of the Business
WALL
and Professions Code, and my license is in full force and effect.
- '"
13 Registers @ 1.75 Ea 22.75
y
0
License Number 380543 Lia Class C-20 _
v
, 1 b 7 A 0
Rancho Air Inc 8-31-89
Contractor f gate
I.-
I. -
• e e • 8 U
I am exempt under Set.
El•
w
_ ..
Plan check fee
1 - y F 3 2 5 N
B.BP.C. for this reason'
1 0
Date:
PERMIT ISSUING FEE $
_
••+5.'x2Sm.
TOTAL FEE 5325
SignatureO
09,20-88
WNER-BUILDER DECLARATION
PLAN CHECK APPLICANT
1 hereby affirm that I am exempt from the Contractor's License
► -
Law for the following reason (Section 7031.5, Business and
NAME
Professions Code):'-
III
.. V I, as owner of the property, or my employees with
ADDRESS
J-- wogesas their sole compensation, will do the work and
CITY TEL. NO.
the structure is not intended or offered for sale (Section
7044, Business and Professions Code). - �-
OWNER
❑ I, as owner of the property, am exclusively contracting
The Anden Gro up
with licensed contractors to construct the project (Sec- -
ADDRESS IL 1074 Parkview- Drive #201
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY -
CITY.- Covina, TEL. 110.$18-967'95)(1
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued -
CONTRACTOR ' ' RANCHO AIR INC.
,
(Sec. 3097, Civ. C.).
-
. - ....
ADDRESS..
Stref-A.
Lender's Name
1232 H_ qtb
- -
CITY .. TEL.
Lender's Address
01 7A6
I certify that I have read this application and slate that the
STATEM.
LICENSE NO. 380543 CLASS C-20
- - -
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
- - --- -
andherebyauthorize representatives of this County to enter
-
upo the bove-menHoerd property for inspection urposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signafure of Applicant or Agent Dole
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