HomeMy WebLinkAbout1058A • 1�JORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT � � �
I hereby affirm �hat I hove a certificate of mnseni to self
insure,or a certificare of Workers'Compensa�ion Insurance, �oA364C . ...._,.�.�E,ATI�IG, -.,VENTILATING - AIR CONDITIONING ,
or a certified copy thereof(Sec.3800,Lab.C.) ^v
CE-018 fREV.10/871
P❑olicy No.3�jn5�3 Company r.—�n
Cerii4ied copy�s hereby fur�ished. COUNTY Of LOS ANGELES BUILDING AND SAFETY
aCenified copy is filed w�th the munty building inspec- FOR APPLICANT TO FILL IN BUiIDING
no�department. ADDRESS 24204 E. Sylvan Glen Road
(PRINT OR TYPE ON�Y)
pa,e 5-29-88 Applicant Rancho Air, Inc. �ocaurv Diamond Bar Buildin s A-H
NO. ?VPE OF APPLIANCE OR EQUIPMEN7 F:E
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE ceosssr. Tr.act 437 b JOb O
(This secfion need not be compleeed if the work involved hy /+BSORPiIaN uNli,eiu oicTk�a No. =eoces5=.o 6r
the permif is for one hundred dollars(5700J or less.)
I certify that in Ihe performonce of ihe work for which this /�IR HANDLING IJNIT,CfM d o q �
permif is issued,I sholl not employ any person in any manner ��
so as to become subject to ihe Workers'Compensotion Laws. BOIL£R,BTU apPeovA:s oare w5aecroRB S�G�v.oruee
Date ApplicaM � COMPRESSOR,etU O OO 40LGH /(J /� 7 �,
"`�iICE TO APPLICANT: If, ofler making fhis Cerfifi<ale of VENTILATION SYSTEAA F�NAi � 3 cji
+. nption, you should become subject to ihe Workers'
L�r�npensafion provisions of the Labor Code,you must forih- EVAPORATiVE COOLER VALIDATION
with comply with such provisions or this permit shall 6e
deemed revoked. FURNACE: FAU GRAVITV
LICENSED CONiRACiORS DECLARATION F�OCR ei�
I here6y affirm that I am licensed under provisions of Chapter 9 HEATER- � SUSPENDEo UNIT_
(commencing with Section 7000)of Division 3 af the Business �'//+�� %-� Cl�'.��
and Professions Code,and my li<ense is in full force and effeci. , �'
56 RegisLers @ 1.75 9 00 ;; a o � ,g �-
License Number �RnS�L� Lia Class�:—��1 , t!
i ��U��� {At
Coniroctor R nr��o Ai?'.� Trimpte �—�1—A9 c a[p;};j�^,z �
❑ I om exem t under Sec. �'� �w
P � .r_f�—R %
Plan check fee �
B.&P.C.fo�this reaso� pERMIT ISSUING FEE$ 10 50 �
Date:
Signat�re TOTAL FEE
OWNER-BUILDER DECLARATION ���N CHECK n?PL!CArvT
I hereby affirm that I am exempt from Ihe Coniroctor's License ►
Law for the follewing reason(Section 7031.5, 8usiness and NAME
7rofessions Code):
I, as owner of ihe properry, or my employees with A�DRE55
���✓ woges as their sole compensatian,will do the work and CITY TEL NO.
the structure is no1 intended or offered for sale(Secfior
7044,Business and Professions Code). '
OWNER
❑ I,as owner of ihe properiy,om exdosively<onfrdciing �
with licensed contrqc�ors to construc�the projecl(Sec- MAIL �t
tion 7044,Business and Piofessions Code�. ADDRE55 1074 Parkvie�r Di 1YE 7�2�2
CONSTRUCTION LEN�ING AGENCY ��T� COV1T18 CA iE�'N 'Bl$J 7— �1
I hereby affirm 7ha�there is a mnsirucYion lending agency for ,
the performance of the work for which this permit is issued CONTRAC'O�'
(Sec.3097,Civ.C.).
ADDR[55
Lender's Name
arr U la.nd TEi."0.(714) 981-�SS
Lender's Address
STATE � LIC.
I certify that I hove read this applicafion and stale ihal ihe LICENSE NO. �y CLA55 —QQ
above informotion is ec�.I agree to wmply with all Counry
ordinances and State lows reloting to building construction,
❑nd ereby authorize representatives of this Co�nty to enter
u ihe obove-me oned property for pin�sp��ection pp�rposes. SEE REYERSE FOR EXPLANATORY IANGUAGE
� d"✓7�-i3 1
Signa re of Applicant or A ni Dafe
S310N S,AJO1J3dSN2
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