HomeMy WebLinkAbout1691A �WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT �
♦I hereby affirm that I have a certificale of tonsent ta self
insure,a a cerufimte of Wwkers'Compensotion�nsurorxe, 76A�� HEATING - VENiILATING - AIR CONDITIONING
or o certified copy thereof(Sec.3800,lab.C.)
��Y No PWC 0506����Y Golden Eagle Ins,CE-818(REV.10/Bf)
Canif�ed copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is filed with th�co�nty building inspec- FOR APPLICANT TO FILL IN Bu��o��vG 7k5 View I.811@
tion depariment. (pRINT OR TYPE ONLY) ADDRE55
oa,e 5-2�89 ApplicantRaY1'(.�lO A].TF Inc. ����Tv Diamond Bar Tract# 1t2582
NO. TVPE OF APPIIANCE OR EOUIPMENT PEE
CERTIfICATE OF EXEMPTION FROM WORKERS' CRO55557. L�YP� 2�j dob� 876
COMPENSATION INSURANCE
(This caetlon naad�wt b�complN�d tf tha wodc Inwlved hy A�RPTiON UNI7,B7U �ISiRICi NO. PROCESSEO BY
Th�p�rmit is for ono huedred dollors(i100)ur lass.) AIR HAN�LING UNIT,CfM �l \
1 cenify thot in the performance of Ihe work far which this �(J �o.`a1'C
permit is issued,1 sholl not employ ony person in any manner BOILER,8TU
so os ta become suhject ta the Workers'Compensotion Laws. nvaaov�is DATE INSPECROR'S SIGNATURE
1 COMPRESSOR,8TU 60.000 ZO OO ROUGH
Dote A.rplicont
[ 'ICE TO APVUCANT: If, after mnking this Ceriificafe of VENTILATION SYSTEM FINAL Z-2 �
[, .nption, you should become subjecf fo the Workers'
Compensoiion provisions of fhe Ln6or Cade,yau musi forth• EVAPORATIVE COOIER VALIDATION
with comply with sucb provisions or this parmit shall be
deemed revoked. 1 FU�R CE: FA�L� ev��QU�— io 00
LICENSED CONTRACTORS DECLARATION
I hereby a$irm thot k om licensed under provisions of Chapter 9 HEATER: SUSPENDED UNR_
�(commencing with Section 7000)of Division 3 of the 6usiness � WALL
and Professions Code,ond my license is in full force ond effed. � d
13 Re isters e 1. Psa 22 �� � • � ti p
License Number��5�3 lia Class C-20 a � � � ; V
Rancho Air Inc 8-31-89 ► t-F o
Controcror � bate
a l . �5�c.5 u
1 am exempf under Sec. -i,. _ W
Plan check fee • � � c.,.; .:� y
8.8P.C.for�his reason
PERMIT ISSU{NG FEE S Z
Dote: �i'.G Q—c;'''
S�gnawre TOTAL FEE 'Z
OWNER-BUILDER DECLARATION P��+N CHECK APPLICANT
i hereby affirm that 1 om exempt from the Coniractor's License ►
Law for ihe following reason (Section 7031.5, Business and NAME
,�•fessions Code):
L ADDRESS
� I, as owner of the property, or my employees with
wages as iheir sole compensnlion,will do ihe work and ���, �� �
Ihe structure is not intended or offered for sale(Seciion
7044,Business ond Professions Code). OwNER The And.en Group
❑ 1,as owner of the property,am exclusively coniracling 1.
with licensed confraUors fo conshud fhe project(Ser qpDRE55 107�+ PB.I'ICYleY DT1Y2 �2�1
�ian 7044,Businets and Professions Code).
CONSTRUCTION IENDING AGENCY Qiv COP1I1&� re�.N�lg_967_g5y1
I hereby offirm that Ihere is a conshudion lending agency for �
�he performance of 1he work for which this permit is issued CONTRACTai
(sec.3o9'r.a�.c.�. Rancho Air Inc.
ADDRESS 1232 W. 9th Street '� � -
Lender's Name ii,, �
Lender's Address ��ry "Y�d TE`-NO� 71�+-981-480
STATE 1' LIC.
I certify that I have read ihis applim�ion ond stale that the IICENSE NO. 3SO 43 CLA55 �.'-2� �
abova information is correct.I agree to compiy with all County
O�dinpntes and S�ate laws relaling to building consiruction,
and hereby auihorize representotives of Ihis County to enter �
vpon e ove-men�io e�d properly for inspection p�rposes. SEE REVERSE FOR EXPLANATQRY LANGUAGE
��� ��y�� '
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