HomeMy WebLinkAbout1667A (10) . WORKERS•�oMPENSAT�oNOE��RAT�oN . . APPLICATION FOR PERMIT �
� I hereby o(frrm thet I hove a certificate of consent�o se�f .
;iZsore,or a certificme of Workars'Compensation Insuronce, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereoi(Sec.38D0,Lob.�C.) 76n36aC
CE-818(REV.10/61 J .. . .
PolicyNo.�C O OF)��m�„y Golden Eagle Ins.� � -�
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Cedi(ied copy is filed wilhihe county 6uilding inspeo- - FOR APPLICANT TO FILL IN BUiLDWG
nooRess
fion department, (PRINT OR TYPE ONLY) �
Date 5-29-89 qpp�icanrRancho Air. Inc. iar+un' Diaznond Btu Tract� 42582
.NO. TYVE OF APPLIANCE OR EOUIDMENT . FEE
CERTIFICATE OF EXEMPTION fROM WORKERS' . NEARESt -
COMPENSATION INSURANCE � � � CRO55 5L LO$� 1 Job# 876
(This svcilon naod nof ba compla}od if The work fnvolved by . ABSORPTION UNIT,BTU DISiNICT NO. PROCESSED BY
tho pormit fs For one handrad doilars(S��)e�lass.� q�R HANDIING UNIT,CFM � t
I�certify ihat in the performance of the work for which ihis �D �0.\O�'e
_ �permit is issued,I shall not employ any person in any manner - BOIIER,BTU —
�so os to become subjetl to ihe Workers'Compensation laws._ ncvaovnts onh INSPEROR'S SIGNATVRE
Date � �Applimnl � � � �' COMPRESSOR,BTU 60�000 Z .00 gpUGH D� ... .
NOTICE,TO APPLICANT: If, affer moking Ihis Cerlifitole of VENTILATION SYSTEM . FINAL L- _
' �mption, you should become subjeU to ihe Workero' . � �
S, pensation provisions of the Lobor Coda,ybv must forih- ¢VAPORATIVE COOLER VALIDATION
�with mmply with suck provisions or Ihis permii shall be �
� deemed revaked. . .' � -- . � ' ' �-- 1 FURNACE: � FAU.7�_GROYJTYOQO_ 10 00 .
LICENSED CONTRACTORS DECLARATION �, F�ooa eiV 1VU �
�- I he�eby a(firm thal I am licensed under provisions of Chapter�9 HEA�R: . SUSPENDED �UNIT_ - .
'(commencing with Seclion 7000)af Division 3 of the Business WA«
and Professions Coda,and my license is in full force and effect. � - � . �" � � y
13 Re isters @ 1.75 �. 22 75 0
.. license Number 380543 �u�.ciass � C-20 _ . , � v
Rancho Air Inc 8-31-89 `� 6��A o
Contmdor � 9ate �� �� •8 �-.
_ O . . . _ . . .. e e V
I am ezempi under Set. �
. , PI6n check fee � � y F 3 2 5 �
B.BP.C.for this reason' pERMIT ISSUING FEE S 1 O _
Date: • • +5a�5%�
TOTALFEE 53 25
SignaWre 0 9.2�—8 8
� OWNER-BUILDFR DECtARAT10N � � PLAN CHECK APVUCnNT .
I hereby affirm that I om ezempt from�he Contmctor's License ► -
Law for Ihe following�eason(Section 7031.5,Business and NAME � � . '
P���ro---IIIfessionsCode): � � � - - � . --�
.. V I,os owner of the property, or my employees with ADDRE55 . . .
J --wogesus Iheir sole compensofion,will do the work and GITY �TFL.NO.
ihe structure is not intended or offered for sale(Section
7044,Business and Professions Code). :- �-� � OWNER �
❑ I,as owner of Ihe property,am extl�sively controtfing �1e Anden Gro
wirh licensed controcto�s to mnsrrucr the project(Sec- � A�oREu 107�# PaTkV1eW-Dr1YC' �2�1
lion 7044,Business and Professions Code). ' �
CONSTRUCTION LENDING AGENCY � �' GIN.-� QOP1II3� � TF�•N��H�-H-96T'95�1 �
I hereby affirm that there is a tonstruttion Iending agency for , ,
ihe performance of Ihe work for which this permit is issued - CONTRa.CTOR ��'RARCHO �LIR INC.
(Sec.3097.Civ.C.). . � - - � - .. ... .. ..
. - .... ADDRE55.. . - ..... .. ._ ....._'.�� . . _:.�. �.�_. ._.. .___ .___. _
Lender's Name •
- - CITY . ... _ . TEL.NO. . .. _._. � .
lender's Address � �
STATE 1. IIC.
I certiiy�hat I have read rhis appl�ca�fon ond slole thaf the- UCENSE NO. 380543 � CLASS � C-2O �.. ' - .� .. _
obove information is correct.I agree to comply wi�h ail County �
- ordinonces and State laws rela�ing to building mnstruction,_ _ _ __ _ �
. . �._.. _ _ . . . ._.. . _ . .
and hereby authorire representatives of this County to enter - �� � �� -� � -�-- � - �
up�e bove-mentio�d properry for inspedion frposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
a _ _ -- -
$ignalure of Applicanl or Agen� � �1a . .. - - . . . _ .... . . . ... . .. .. ... . .. .. . .. "'
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