HomeMy WebLinkAbout1692A �WORKERS'COMPENSATION DECLARATION qpp���ATlOiil FOR PER�ftiT �
I hereby affirm that 1 Vrove a certificate of consenl to self
ins�re,or a cerrificote of Workers'Compensotion�nsuronce, ��3�� HEATING - VENTILATtNG - AIR CONDITIONiNG
or a certified copy thereof(Sec.3800,Lab.C.) CE-8�8(REV.10/81) �
acy No.�r nsn�r�,,,r��v s.
Certified copy is hereby furnished. COUNTY OF 40S ANGFIES BUILDING AND SAFEiY
� Certified copy�s filed with tha county 6uilding inspec- FOR APPLICANT TO F{LL IN eUi�oiNG
fion deparfinent. (PRINT OR TYPE ONLY) ADDRE55 735 Viev L8.II2
pote 5-29-89 APPliconf�C}lO AlP� IIIC. LOG4LITY Diamond Bar Tract 42 2
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFiCATE OF EXEMPTION FROM WORKERS' NEaREST
COMPENSATION INSURANCE CRO55 5T.LOT 2
(Th4 sxtion naad no►be tompbl�d if fha work involwd by ABSORPiION UNIT,BTU O�STRICi NO. Vlio[ESSED Bv
iho parmll b for on�hundnd dvlbrs(5100)or Ios�.) AIR HAN�LING UNIT.CFM �Q (1� ' '
1 tartify fhat in the performance of�he work fa whith this ���q qI��
permit is issued,I shall not employ ony person in any monner gOaER,BiU
so os ta 6ecame su6ject to the Workers'Compensation Laws. L aPaeovnis oare INSGEROR'S SIGNAlURE
p��e oPP�.�o�� 2 COMPRESSOR,BTU 3u�OOO 2O OO ROUGH i
�� ICE TO APPLICANT: If, afler making this Certificate of VEN71tA7�ON5Y5TEn4 F�NA� jL` — I
-e. _mption, you should become su6ject fo the Workers' �
Compensation prorisions of the Labor Code,you must forth- EVAPORATIVE COOIER VALIOATION
wilh comply with such provisions or this permit shall 6e
deemed revoked. 2 FURNACE: FAU_C�VI�'Q� 20 QO
LiCENSED CONTRACTORS DEQARATION FLOOR BTU �
t hereby affirm thot 1 am Ncensed under provisions of Chapter 9 HEnTER� �SPENDED UNIT_
�(commenting with Section i00D)of Oivision 3 af!he Business ' 'NAi�
and Professions Code,and my license is in full 4orce and effect. ir� ftGgiB'tP,PS � �-.75 $a N `�5 �
380543 c-2o 0
License Num6er �ic.Clau � � 1 ��.�_�_ V
Rancho Air, In�+. 8-31-89
OC
Contmttar Date j)• a • • .t; �
❑ I am exempt under Sec. c y�
Plan check fee � a `��•%� d
B.&P.C.for ihis reason v�
PERMIS ISSUING PEE S 10 50 �• . ,. - �
oate: • ;: . •.
TOTALPEE 76 75
5ignarure 0�i',G Ci—.;�':
OWNER-BUILDER DECLARATION PLAN CHECK APPi.iG4Ni
I hereby affirm thot I am exempr from the Comractoi s Liceose �
Law for the following reason{Sedion 7037.5, Business and NAME
' Fessions Code):
��._ I, os owner of the properly, or my emplayees with AWRESS
wages as their sale compensotion,will do the work and
ihe strod�re is not intended or offered for sale($edion ��TV TEL NO.
7044,Business and Professions Cade).
OWNER � �den Group
❑ I,as owner of the property,am exclusively mniracting
with licensed contractors io canstr�ct the project(Sec- �"�A�� 1'
lion 7044,Business and Professions Codej. P.D�RESS _ y ,Pgr ��F7 ]�'].YC' 2 1
CONSTRUCTION LENDING AGENCY Oiv COV�2n, TE�.No. -8z8-967-954
I Mereby affirm that there is a construction lending agency for ,
the performance of�he work for which this permit is issued CONTRACTOR �(,`$Q f}j$� jj�j(,'.
(Sec.3097,Civ.C.).
ADDRE55 �� �, h Street �
Lender's Name
CITY TEI.N0.
Lender's Address � �
I certify that I have read this application and s�ate that the iic�Nse r,o. 380543 C1A55 C�20
obove information is correct.I agree to comply with all Counly
ordinances nnd State laws relating to building construction,
and hereby authorize representatives of ihis County to enter
upo he ove-menti ��d property for inspecrion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
-�2 -g8'
Signal�re of Appliconr or Agen� Date
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