HomeMy WebLinkAbout1690A (223) 'WORKERS'COMPENSATION�ECLARATION qppLICATiON �OR PERMIT �
1 herehy affirm that I have a cartificate of consenl to self
Insure,or a certificate of Workeri Compensafion Insurance, 76A�C HEATING - VENTItATING - AIR CONDITIONING
or a tertified copy thereof(Sec.3800,Lab.C.) CE-eiB(REV.10/81) �
P�o�icy No.�C OrjOE).��m��Y GOlden Sagle Ins.
Certified copy is hereby furnished. COUNTY OF LOS ANGEIES BUILDING AND SAFETY
� Certified copy is filed with the county building inspec- FOR APPLICAPIT TO FILL IN eVIiDING
tion department. ADDRE55 vl y
(PRINT OR TYPE ONIY)
Dore 5-29-89 Applicant��nCho Air. Inc. IOCAUTY Dismond Bar Tract� �2582
NO. TYPE OF APPIIANCE OR EOUIPMENT FEE
CERTIFICA7E OF EXEMPT�ON FROM WORKERS' NEARE57 ��� 2J� JOb(/ $'jC)
COMPENSATION INSURANCE CROSS Si.
(Thls e�efion ne�d not ha eomplotod if tho work tnvolr�d by ABSORPTION UNIT,BTU oRrai[r No vROCesseo ev
tha pvrmit{s for on�h�ndnd deflon(;100}or le��.) q�R HANDLING UNIT,CFM �D
I certify thot in the performance of the work for which this �0.����
permil is issued,I sholl not employ any person in ony manner gpILER,BTU
so as to become sobject to the Workers'Compensation Laws. aaaeovnis onr¢ INSGECTOR'S SIGNA7URE
2 COMPfiES50R,BTU ��0� 20• Q ROUGH
Dote� epplimnt 0 j 8
� 'ICE TO APPLICANT: If, affer making fhis Certificate of VFN7ILATION SYSTEM FINqI + _ZZ-�
�nption, you should become subiecl to the Workers'
Compensation provisions of rhe labor Code,you must for�h- EVAPDRATIVE COOLER VALIDATION
with comply with svch provisions or this permit shall be
deamed ravokad. ,� FURNACE: FAu�C�GB.Y1iY�_ 20 00
LICENSED CONTRACTORS DECIARATION FIOOR B7u 6U UlJ �
I hereby affirm that 1 am licansed urder prnvislwu of Chopter 9 SUSPENOED UNii_
HEATER:
�(commencing wi�h Section 7000)of Division 3 of the Business WALL
and Professions Code,and my Iicense is in full forte ond effecL �� ��.'r�", �
15 Re isters @ 1.75 Ea 26 25 'i
License Number38o543 Lit.Class C�2d r• • • - °;`' V
�,iancho Air Inc. 8-31-89 � I . r 7�7� �
conrrac, � Do,e Or
❑ 1 am exempt under Sec. .. c r%�..,';',- W
Plan check fee " "
B.$P.C.for this reoson ZO rjO ��•�C—�-�%� Z
Dale:
PERMIT ISSUING FEE S
Signature TOTAL PEE 76. 7rj
OWNER-BUILDER DECLARATION PLAN CHKK AP7LICANT
I hereby affi�m thal I am ezempt fram the Coniractor's License �
law lor the following reason(Setlion 7031.5, Business and NAME
P•�fessions Code):
� I, os owner of the properly, or my employees with ADDRFSS
wages as their sole compensatlon,will do the work ond
• Ihe strutture is not intended or offered for sa�e(Section CiTv TEL.NO.
7044,Business ond Professions Code).
❑ OWNER �e Anden Grou
I,as owne�of the property,om exclusively contracting
with licensed comroctors to consiruU the projeU(Seo- ��� 1074 Parkviev Drive �2�1
lion 7044,Business and Professions Coda). AODREss
CONSTRUCTION LEN�ING AGENCY ��7Y C���� re�.No. g18-967-95k
I heraby affirm that there is a construction lending ogency for �
the performance of the work for which this permi�is issued CONTRAC70R�N.�� � �L..
(Sec.3097,Civ.C.J.
ADDRE55 1232 W. 9th Street �
Lender's Name 1�
CRV Up� TEL.N�1�—CJ81-4SO1
LendePs Address
I certif ihat 1 have read�his a Gcafion and s�ate�hat the STATE uC.
v Pa uceNs�No. 380543 c�Ass C-20
above information is corred.1 agree to comply with all County
ordinances and Slate laws reloti�g to building construction,
and hereby authorize represematives of this Counry to enrer �
upon e ove-menti ned p.operry for inspedion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
_ � �a,� �•���-�
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