HomeMy WebLinkAbout0613A WORKERS'COMPENSAiION DECLARAiION AppLICATION FOR �PERMIT . �
I hereby affirm �hat I have a certificate of consent to seR .
insure,or o certificate ot worke�s Compensafion Insuronce, �bA364C HEAT{NG - VENTILATfNG - AIR CONDITIONING
or a cerfified copy thereof(Sec.3800,Lab.C.) .
CE-81B(REV 10l87)
P�oi�icy No. -T'' 21926 comp��y Fair�ont Ir.s. . - � � � �
Certified copy is hereby furnished. COUNTY OF l05 ANGELES BUILDING,AND SAFETY
� .. .,. ,.:.,-, ,.. . ...-, .,, ,,,_ ,. ., .
Cerrtied copy is filed with ihe county bwlding i�spec- POR APPIICAN7 70 FILL IN sui�oiNc
fion deportmeni. ADDRE552�}37� E. S lvan Glen Rd. ot
(PRINT OR TYPE ONLV;
oare 5/29187 Applicont Rancho Air�Inc. "" '" ' �ocaurv . _
NO. 7VPE OF APPLIANCE OR EQUIPMENT FEE D
CEf2TIFICATE OF EXEMPTION FROM WORKERS' Ne.4RE5i
COMPENSA710N INSURANCE � cRO555i.
(This secfion need nof be complefed 1f ihe work involved 6y /aB50RPTION UNIT.87U DIS'GICT NC. PRCCESSED BY
The permif is for one hundred dollars(5�00}or less.) qiR HqNp��Nc uNli,cFM
I certify ihat in the performance of the wark for which this
permil is issued,I shall not employ any person in any manner gOIiER,e7U
so os ro 6ecome subje<t�o ihe Workers'Compensation Laws. naaacvn�s onre iNs�ecroa's sicNnruae
��'q Apo�lcan� � COMPRESSOR,BTU_ij On0 �O OO ROUGH ��j`� ��
� ICE TO APPIICANT: If, afler making ihis Certifimte af .� . VENTILA7iON SVSTEM 1 O F!h/+� �. _�d
h..emption, you should bemme subjeU to ihe Workers'
Compensatian provisions of the Labor Code,you mosf forlh- EVA70RATNE COOIER VALIDATION
with�compiy with such provisions or ihis permit shoil be '
deemed re�oked. FI;RNACE: FAU_GR VTY
LICENSED CONTRACTORS DECIARATION � ' i FLOOR BiU IO OO
I hereby affirm thot I am licensed under provisions of Chapter 9 � SU57ENDE� UMT—
HEATER�. WALL � ��
�(mmmencing wifh Secfian 700D)af Division 3 of rhe Business ��i�(i
and Protessians Code,and my license is in full force and effect. �
Re isters 1. ;�:o s � s e g �
Llcanse Number J805�� �Ic.Closs c-2� �
co�va�ro, Rancho Air,Inc aare �?/3l/87 , � �g~�� ��' O
�
� �� �bt'',%�� v
I om exempt under Sec- py
Plan check fee ; �,_ �.
B.BP.C.for this reason � � - � � �'� , �+O �
PERMIT ISSUING F�E$ 10 50
Date:
Sig�ature TOTAL FEE
OWNER-BUILDER DECLARATION PIAN CHECK AFFLICAM
I hereby affirm thot I am exemp!from ihe Controctor's License ► �
Law for Ihe following�eason (Sedion 7031.5, Business and NA�viE
F"�"'essions Code):
u I, as owner of the properry, or my employees wifh ADDRESS
wages as their sole compensotion,will do rhe work ond
�he siructure Is r.ot in�ended or offered for sale(Section ��TY iEL.NO.
7044,Business and Professions Codel. �
OWNER
❑ L as owner of�he property,am exdusively contracling MAIL m '
with licensed confradors to construct fhe projec�($ec- ADDRESS l� �} '�a,r]rV1 S�7 ,�P1VC' 2�l
tion 7044,Business and Prafessions Code). —
CONS7RUCTION LENDING AGENCY
I hereby offirm ihol ihere is o mnsfrudion lending agency for CITY L,OV1pa TEL NO. 67^ �l ►
the pe�formance of the work for which this permit is issoed COh'TRAC70R �
(Sec 309�,Gv.C.i. RanCho A7 r Inc.
aooeess 12 2 YT. tn St.
Lender's Name
tendei s Address Oiv U ��ra iEt NO. 1_�4 �1
STATE p I�p LIC.
i ce�nfy rhar i ha�e read�h�:aPpu�ar�o�a�d srare�har rhe LICENSE NO. 3t�OS`�.J anss C-20
above Informotion rs correct.I agree to comply with oll Counry
ordinances and State laws relating to 6uilding constructian,
and hereby aulhorize representatives of Ihis County to enler . ' �
upon�above-men�o ed properi� inspe n pur ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signo:�re o�Aoplic n or A�e��t a�e ,
�aA3�S�E�ii?�'S�t3�"eS OWIVER-SllILiJ�R DEGEARATI�N
� . nereby cfSirrr fhat I am exempt*rom�the Contrecte(=_
- ' - -- i.�.cerse '_._m for r4,� ¢ . �ir.g r iSeci�on i037.5
._ ' . -rznd�'ro4e;slo�s Codo;:Ar�y d+y o;ccan^y vshld,
, , � � � requices o p�rmiP ro:cistruci,alfer,improve,demalish.
' � cr repoir orty sfructur„�rior fo i4s i ,. also rc�
- ` � '� quires}F;,e applicont fcr such permi;to fi!s a sign�d sVcte-
- _ � � � rnant that he is fimnsed uursuanf Pc ine p�cvisions of fhc
ConPrdnor's:icensQ l.aw(Chap�cr 4!co,n . ing�..,ih
� � �aCicn?ODO�otl Division 3-of�iF.e Susinsss and P;c;c:-
�sions Cod��or fhan c�is r�pr tnerefrcrn�ar,J tne bo�is
;or t8e �Ifeged exem.p��on. Ary •riola;ion oi 5
� � � 763f.5 6y ar.q applicunr for a parmit subjecFs!he ap,oii�
. . ccrxP 7o a c vil�encity of nof more tban five hun..✓,red
. . � -- _ do!!ars!S50G'.. � .
^_'_ _ []'. . m.�-.;F,I:e prca<:r:y+aill de'F��..aorL;a.o
_; .�a , , � �he struc:�re s ooi��,n'e^:ded or cffered for sola.
�� ' �� ' ___ _ (Set,704d,Susiress ana'Professions Code: The(. rac-
=s Licer.se Low does not oppfy;o an c�r✓mar of properly
- .who Suilds or imoroves rnerecn. nnd who does such
--�----------- :.`<himceG provids-d'rha:s�ch rmprov�m�nis ar�noi
� v-r�ndeJ or of:ereo'!o:sole If,norverer,'h-bv;lr.'ir5 0�
. . � i;nprove,ner.f is sold within ene yedr el co�-iple;ian,�he
owner-bui;der voit!have Ihe burden o4 p,-oving tFot he did
. , noi bui(d cr+.'mprcve!ar 7h,e purpuse o9 sale.)
. __.__ _____ , ❑I,as ev�.ner o'i ihe properSy,a� xclusi�Jely con-
t-acfleg�rri4h lican�sd conircctcrs b sonsr�c'the projea
_ ____ A_____ �Sec.70a4j Eusiness and Protassror,s Code�7hn Ccr�;r�:
.for's Li<ense Law dces nat apply to ar awr.e�of Croperty
____ _ v�ho Suifds or imo!ov2s'rheraan,and who rortrocis ior
such�ra(�qs wirh p consrccter(sj(icensed pursonnr ro
!he Contro.-;or's Cicer�se Law;.�
'om oxerript�;;dsr Sac'
B&P,C.for this reason-
. Dase �----�------- -
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lNSPECTOR'S NOT6S