HomeMy WebLinkAbout1685A (221) • WORKERS'COMPENSATION DECLARATION APPLiCATiOfV FOR PERiifilT �
. I here6y affirm thot I have a cerrificate of consent to self
, insure,or a certificare o4 Workers'Compensation�nsurance, �bA� HEATING • VENTILATING - AIR CONDITIONING
or a certified topy thereaf(Sec.3800,Lab.C.)
Q�YNo.Pwc a5o6�m��Y Golden 1��1e Tns.�E-a�e�Rev.�oiei>
Certified copy is hereby furnished. COUNTY OF LOS ANGELES 8UlLDING AND SAFETY
� Certified mpy is filed with Ihe touMy building inspec- FOR APPLICANT TO FILL IN BUttDING
ti6n departmenf. ADDRESS 71�6 View Lane
(PRINT OR TYPE ON�Y)
Da�e 5-29-89 APPlican��cho Air, Inc. iocnurv Diarmond Bsr Tract�t 42582
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEnREST �j� 19 Job# 876
COMPENSATION INSURANCE Ctt055 ST.
(ihls sxfion naa!nvl ba eomplsted il tho work Involvod 6y �+BSORPTION UNIT,BTU D�Si21C7 NO. VWOCESSED BY
tha permit le ior one hvndrod dullan(SI00)or loss.) qIR MANDIING UNIT,CfM ��
1 certify thaf in the performonce of Ihe work for which this �\O(�e
permit is issued,I sholl no1 employ ony person in ony manner BOILER,BTU
so os to become subject to the Workers'Compensation Laws. L arvaovA�s onre �NSPECiOR'S SIGNATURE
Date Appliconf COMPRESSOR,6TU vO�OOO ZO. O ROUGH �
NOTICE 70 APPLICANT: If, after making Ihis Certificate of VEN7ILATION SYSTEM FINAL
� xemption, yo� should becoma subject �o fhe Workers' `
.:ompensation provisions of Ihe Labor Code,you mvst forfh- EVAPORA7IVE COO�eR VALIDATION
with comply with such provisions or this permit shall 6e
deemed revoked. 1 FURNACE: fAU�g1iFYIT`L.m_ io. O
LICENSED CONiRACTORS DECLARATION FIOOR eiu vv�tlVll
I hereby offirm that 1 am licensed under provisions of Chapter 9 HEATER: SUSPENDE� UNIT—
�(commencing with Section 70W)of Divisian 3 of the Busineu � WAtI
and Professions Code,and m license is in full force ond effect �
Y 13 Registers @ 1.75 � 22. 5 `i �� �� O
License N�m6er 3a0543 Lic Class C-20 ^ V
��a • • . e)•.
Conhacror�ChO 1�1P� ZIIC.pate $—�-89 � • c ���.;-� O
❑ I om eaempi ander Sec. + ` �`- - ` �
Plan check fee ='-' .
8.8P.C.for this reawn y
PERMIT ISSUIPIG FEE� 10. 0 0 4 2 C_�:', Z
�ate:
TOTALFEE 53. 5
Signature
OWNER-BUILDER DECLARATION 71AN CHECK APPLICANT
I hereby affirm thot k om eaempl from the Contrador's license ►
Law for ihe following reoson(Section 7031.5, Business and NMAE
Pr—ro�fessions Code): .
f J �, as owner of ihe property, or my employees with ADDRE55
1,., wages as fheir sole compensation,will do the work and ���, TEL.NO.
the structure is not intended oi offered for sole(Sedion
7044,Bosiness and Professions Code). OWNER
❑ I,as owner of fhe property,om exclusively confra[ling The Anden Gro
with licensed confmctors lo construcf�he project(Seo N`p'��
tion 7044,Business and Professions Code). ADDRE55 '
CONSTRUCTION LENDING AGENCY ��r - cov3na, � � ����� Si8-967-95k
I hereby af4irm thot there is a construdion lending agency for ►
the performance of the wo�k for which this permit is issued �pN7RACTOR ��p Ajj;� jjQ(,'.
(Sec.3097,Civ.C.). -- � . .
ADDRE55 1•Z 2 {'�. th Street
Lender's Nome 1- o, `.On
arv Upland TEL NO. 714—g�.a.-4�Jv
Lender's Address
STATE LIC.
I rertify that I have read this applimtion and slate that the ucer,se No. 3805�+3 � cuss C-20
above information is correct.I agrea lo comply with all County
ordinances ond State laws relating�o building cons�ruction,
and here6y authorize representatives of this Coumy ro enrer
upon a a ve-mention�property for inspedion purpases. SEE REVERSE FOfI EXPLANATORY LANGUAGE
-a - �
Signature of Applicant or Agent Date �
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