HomeMy WebLinkAbout1684A WORKERS'COMPENSAi�ONDECLARATION qpPLiCAT10N FOR PERMIT �
I hereby affirm�hot I have a certificate of consem to seif -
insure,or a certifimte of Workera'Compenspfion Insurance,
br o certifled topy ihereof(Sec.3800,Lab.C.) �enseac HEATING - VENTILATING - AIR CONDITIONING
P❑olity N6��C 0506�-�omponyGolden Tsa�!le Ins. CE-818 fREV.10/BI}
Ce.t�fied copy is hereby t�rnished. COUNTY OF L05 ANGELBS BUILDING AND SAFETY
� Cerrified copy is filed with the counry b�ilding inspec- FOR APPLICANT TO FILL IN BUILDING
tion deporlmCnt. (PRINT pR TYPE ONLY) ADDRESS •
pate���_AppiicanrNunr.ho AirFT,�� ����z�iamond Bar 7.'ract� 42582
NO. TYPE OF APPIIANCE OR EpUIGMENT FEE
CERTiFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CRO55 Si �`J.� 1$ .7ob� 876
(This sacfbn nwd no►ba eomplalad{f�he work Involv�d b A850RPfION UNIT,BTU
tha permit ia for on�hundred dollarc(=100)or loss.) y DISTRICT Np. PROCESSED BV
I cerlify fhaf in fhe performance of the work for whith fhis AIR HANDLING UNIT,CFM � O
permit is iu�ed,1 shull not employ any person in any monner �`Q� �
so as io become subject to�he Workers'Compensolion lows. 9OILER,6711 AGYROVALS DATE INSVECfOR'S$IGNATURE
Date 0ppliconl 2 COMPRESSOR,BTU 36•��0 2�. � ROUGH
NOTICE TO APPLICANT: I4, after making this Certificate of vENtiIATION SYSTEM FlNAI �I _
�� �ption, you should berome subject to the Workers'
penwlion provisions af the Lobor Coda,you mu5t FpffF1- EVAPORATIVE COOLER VALIDATION
w�th camply wilh such provisions o. this permit shall 6e
deemed revoked. fURNACE: FAU�py i�v
LICENSED CONTRACTQRS DECLARATlON 2 FLOOR BTUOU_UU�— ZO.00
1 hereby effirm iFwt I vm licensed under provisions of Chapter 9 HEATER: ��NDED L1NIT_
� �(commencing with Sedion 7000)of Diviaion 3 of ihe Business WAII
and Rofessian:Code,ond my litanse is in full force p�effect. }
1 R isters @ 1.75 Ea 26.25 0-
License N�m6e�805�►3 L7c.Class C-2D
ContraUor�cho Air, Znc�,e 8-3.1-89 , V
:- 16G4ti °G
❑ �
I om exemp�unde�Sec.
B.BP.C.for fhis reoson P�a��heck fee k • � s e •f5 �
Da�e:
PERMiT ISSUING FEE; � ' ` ��'7 i'' z
Signa�ure TOTAL FEE 7(.'TS • . • r C __
OWNER-BUIL�ER DECLARATION %AN CHECK APPLICANT G�.�C�—'-H
1 hereby affirm that 1 am ezempt from the Conhoc�or's License �
Law for 1he following reason�Section 7031.5. Business and NAME
Professions Code):
� 1, as owner of fhe property, or my employees with AO�RE55
� wages as their sole compensoiion,will do ihe work and ��.n,
ihe structure is na�intended or offered for sale(Sedion TEI.NO.
7044,Business ond Professions Code).
❑ I,os owner of the ro er OWNER �1@ Anden Group
p p y,am exdusively conirocting
wilh licensed[onlractors to consfruct fhe proiecl(Sec- DDRE55 1074 Parkviesr I?rive �2�1
tion 704C,Business and Piofessions Code).
CONSTRUCTION LFNDING AGENCY L+OViIlB ���N��818-967-9541
1 hereby affirm thal there is a construdion lending ogency for ��TM s
the performnnce of ihe work for which this permif is issued CONTRAROR �
ISec.3ov�,ci�.C.). RANCHO AIR INC.
ADDRE55 1232 W. 9th Street
Lendeis Nome
Lender's Address ��'Y UP�d '���"�� 714-9g1-48o
STATE ���
I certify fhat I have read this appticotion and sta�e that�he LICENSE NO. �O 43 C1A55 �.'—Q� �
a6ove inlormation is corrett.I agree�o comply with all Coonty
ordinances ond Stafe lows relaring ta boilding construction, .
and hereby a�thorize representa�ives of Ihis County to en�er
upon th abo e-men�ione roperry fo.lnspection purposes. SEE REVERSE fOR EXPLANATOBY LANGUAGE
o� d
Signalure of Applimm o�A9ent Date � �
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