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Home My WebLink About2996AWORKERS' COMPENSATION DECLARATION I hereby, affirm that I have r certificate of consent to self insure, or certificate Workers' Compensation Insurance, APPLICATION FOR PERMIT a eooracertifiedcopythereof (Sec 3800, Lab. C. No. Ci15394 UniL;ard 76AS64C i TING._ - VENTILATING AIR CONDITIONING © CE - 818 (REV. 10/Bt; cy Company -ins. Certified copy is hereby furnished. COUNTY OF LOS ANGELES, BUILDING AND SAFETY CITY Certified cocopy is filed with the county building inspec- tion deportment. FOR APPLICANT TO FILL IN BUILDING I s 268 8 C' OWNER PRINT OR TYPE ONLY; ADDRESS 1 24202 I'" SV1van Glen Road Date 9-88_Applicant R».nnbo I'eir Tnr•, MAIL ' I CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY D-izxnond Bar Blci S . A -H COMPENSATION INSURANCE NEAREST 43756 Job #707CROSSST.TraCt CITY This section need not be completed if the work involved by ABSORPTION UNIT, BTU olsrR!cr CONTRACTOR Rancho A7-.'.' the permit is for one hundred dollars ($100) or less.) 0. o PROCESSED B" 1 93P7 O' I certify that in the performance of the work for which this permit is issued, I shall not employ any in AIR HANDLING UNIT, CFM 1t ., CITY Upland person any manner so as to become subject to the Workers' Compensation Laws. BOdER. BTU LIC. 8 aEraovas ogre wsvECTaR'S SIGNAru RE LICENSE NO. Date_Applicant COMPRESSOR, BTU 30, CCD 80 CC ROUGH NC -CE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL yy ,tion, you should become subject to the Workers' L_pensafion vc+-' provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be EVAPORATIVE COOLER VALIDATION deemed revoked. LICENSED CONTRACTORS DECLARATION FURNACE: FAU_GR.y/,(TY_ O BOOR 87U bUU 8C CC I hereby affirm that I am licensed under provisions of Chapter 9 commencing with Section 7000) of Division 3 the Business HEATER: SUSPENDED UNIT_ of and Professions Code, and my license is in full force and effect. WALL License Number 33051+3 C-20 Re - 56 _Sers 8 00@eT-. Lic. Class Rancho 000.0 IContractorA'r, nCpate, 8-31-89 ft I am exempt under Sec. Plan check feeB.&P.C. for this reason Date: OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business andLaw Code): J" I, as owner of the property, or my employees with wages as their sole compensation, wi II do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). I,as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code1. CONSTRUCTION LENDING AGENCY hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued Sec. 3097, Civ. C.). Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter pan the ab e'1m eniion d property fa, insp ction pur ores. Till`` L 8igna:ure pliccnt or Agent IDate PERMIT ISSUING FEE $ i0 50 TOTAL FEE nFo PLAN CHECK APPLICANT NAME s 2996,A ADDRESS' e s o u e 8 CITY TEL NO I s 268 8 C' OWNER he Anden.Groua MAIL ' I 1 (122-87ADDRESSiZPPOI CITY Covina TEL. NO. (818) 967-9511 CONTRACTOR Rancho A7-.'.' Inc. 0. ADDRESS 1 93P7 O' CITY Upland TEL NC(714) 981-480" STATE LIC. 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