HomeMy WebLinkAbout1683A (225) .WORKERS'COMPENSATION DECIARATION APPLICATION �4R PERMIT �
I here6y affirm thar 1 hove a certifimte of consent fo self
insure,or a certificme of Workers'Compensotion Insurance, HEATIN6 - VENTILATING - AIR CONDITI�NING
or a certified copy thereof($ec.3800,Lab.C.) ����
�c o506�� GO�p.II CE-818(REV.10/BI)
P❑olity No. mpany �,le II1S.
Cerrified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed wiih ihe county building inspec- FOR APPLICANT TO FILL IN BUitDING 732 viev e Lwn r.
tion deparfinent. (PRINT OR TYPE ONLY) p�RE55 �Y
Dote 5-29-89 APPlicanr�Cho Ai2� IIIC. tocnun Diamond Bar T2�dCt� 425$2
NO. TYPE OF APPLIANCF OR EOUIPMENT FEE
CERTIFICATE OF EXEMFfIOh!FROM WORKERS' C OSSS i.LO`P�I 17 Job# 876
COMPENSATION INSURANCE
�T�113 i@C�Wq�MYd 110}�COMP�l1�ii 1ho wurk�wvolvod by ��RPTION 11N1T,BTU OISTRIR NO. PROCESSED BY
1ho pwmlf i�fvr onPhundrod dollan(SI00}or loss.) � „` ��n�
I certif that in the erformance of the work for which this AIR HANDIING UNIT,CFM �
permit is issued,1 shofl not employ any penon in any manner gp��ER,BTU
sa as to become subject to the Workers'COm(JCO50t100 LOWS. L APPROVALS OATE INSPECTOR'S SIGNA7URE
1 COMPRESSOR,BTU W�OOO �.0. O ROUGH
Data Applicont
NOTICE TO APPIICANT: I4, after making this Certificate of VENTitA710NSv5TEM FiNnt �z`� -
� iption, yau should become subjeU to the Wwkers'
�pensa�ion provislons of the Labar Code,yo�mvsr forth- EVAVOR,a7wE coO�ER VALIDATION
with tomply with such provis�ons or�this permit ahall be
deemedrevoked. FURNAC�: FAUY7L— �rr
IICENSED CONTRACTORS DECLARATION 1 FIOOR siU lO. O
I hereby affirm that f am licensed under provisions of Chapter 9 MEATER: SUSPENDED ��NIT_
�(commencing with Section 700D)of Division 3 of the Busineu " Wp��
and Prafessions Code,and my license is in full force a�d effett. }
13 R isters 1. Ea 22. �
license Numbe. 3a05�+3 lic.class C-20 ► �� E�..Y.n V
ContractorRancho Air, IIIC.Dtlte 8��--89 #� ' ' ' °g 0
❑ I om exempt under Sea � • •`z G 5 6
Plan check fee r,-��z '^
B.BP.C.for rhis reason pERMIT ISSU{NG FEE S 10. O ° � ti:'c.�� Z
�a?e: TOTAL fEE �y��G—?>�
Signature
OWNER-BUIIDER DECIARATION PLAN CHECK APPL�CANT
I hereby affirm that I am exempt from the CoMracror's License �
Low for the follow�ng rea:on(Section 7031.5, 8usiness and NAME
Professions Code):
�� 1, as owner of�he properfy, or my employees with ADDRE55
� wages as their sole compenwtion,will do the work ond ��TM TEL NO.
" the structure is not inrended o�o4fered for sale(Section
7064,Business and Professions Code). OwNER
❑ I,as owner of the property,am ezclusively contracling
with licensed conimdors to consiruct the proleC�(seC- Ap�E� 107� Parkviev Drive �2�1
fion 7044,Business and Proiessions Coda).
CONSTRUCTIQN LENDING AGENCY CITV COyiIIB� '���"�818-967-95�►1
I here6y affirm ihaf there is o conslruction fending agency fo� ►
the performance of�he work for which ihis parmit is issued �pNTRACTOR �L.xQ �R INL•.
(Sec.3097,Ciy.C.). ,
ADDRE55 1232 W. 9th Street
Lender's Name
Lender's Address °TY Upl� 'E��NO�714-981-�+801
STATE p 1� LIC.
I cer�ify tha�I have reod this applicalion and s�ate ihat the LICENSE NO. 3pO 43 C1A55 C-2�
above information is correct.I agree to comply with all County
ordinances and State laws relating to building consiruction,
' and here6y authorize representatives of this Coun�y to enter
upon t+aby�ve-�ntion ,praperty for inspectiO�purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signa�uro of Applimnl or Agen� �ate
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