HomeMy WebLinkAbout1686A • WORKERS'COMPENSATIONDECLARATION App��CATl4�+1 FOR PERMIT (
I here6y affirm that i have a certificate of consant to self �
insure,or a certificate of Workers Compensation Insurance, ���� HEATING - VENTILATING • AIR CONDITIONING GS
or a certified copy ihareof(Sec.3800,Lab.C.)'
a�y N,�WC 05061�ompanyG01(IE.'Il F��l P IIIS. CE-818 IREV.10/61)
Cerfified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Cerlified copy is filed with the county 6uilding inspec- FOR APPLICANT TO FILL IN Buno'"�758 v12Y I�SIl@
iion deparfinent. - ADDRE55
(PRINT OR TY7E ONLY)
oare 5-29-89 qPPi;�o„rRancho Air,__Inc. ��i�TM Dismond Bar Tract(I �►25$2
NO. TVPE OF APPLIANCE OR EOUIPMEN7 FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEr+Re57
COMPENSATION INSURANCE CRoss 57. IA`P� 20 Job� 876
(This wtllon n�d no16o eomplefad ii Iho werk inrolr�d 6r ABSORPTION UNI7,BTU pISTRICT NO. PROCESSE�BY
iha pormit is for ona hundnd dollars(f100)or loss.) q�R NANDIING UNIT,CFM ^
I certify thor in ihe performonre of the work fa which this � O ��`p�`o
permit is issued,I sha{M not employ any person in any manner gp�LER,e7U
so w to become subjatt to the Workers'Compensofion Lows, naPCOvaiS DATE INSPECTOi'S5IGNANRE
2 COMPRESSOR,BTII 36.00Q 2Q. 0 ROUGH
Date AtPlimnt , -
f�7T�CE TO APPLICANT: if, after making this Cenificate of VENTILATIONSYSTEM FINAL ��_
!` �nption, you should become subjact to the Workers'
E .mpensotion provisions of the Labar Code,yo�mVsf forth- EYAGpRATIVE COOLER VALIDATION
with comply wifh s�ch provisions or ihis parmit shall ba
deemed revoked. 2 FURNACF. FAU�GR'A}(IZ� 20. O
LICENSED CONTRACTORS DECLARATION FLOOR aTUbU UU
I hereby affirm that 1 am licensed unde/p/ovisiats of Chapter 9 HEATER: SUSPENDED UNlT_
-(commencing with Sectinn 700D)of Dirision 3 ot the 8usiness � �'�'A« �
und Professions Cade,and my license is in full force and effed. - -- - -- - - "`� ��''�f�' �
15 Re 'sters @ 1.7 Ea 2fi. °'
�.. . � .� O
License Num6er �05�3 Li[.Closs C'-20 ► �' N
Controctor R�IICl'!O Air, Inc��e 8-3�-84 � • s ! �. ir� Q
F
� I om ezempt under Sec. � � � � G ` `�= W
Plan check fee a
B.&P.C.for this reason 10. � �i�i'2� �` �
PERMIT ISSUFNG FEE S
Date:
Signature TOTAL FEE 76,
OWNER-BUII�ER DECLARATION Pi.AN CHECK APPLKANT
I here6y affirm thal I am exempt from ihe Contraclor's License �
Law for the fo�lowing reason(Section 7037.5, Business and NAME �
Professions Code):
(^ I, os owner of the property, or my employees wilh A��RE55
'l wages as their sole compensation,will do tha work and
the stroct�ie is nor intended or offered for sale(Sec�ion O7Y TEL.No.
7044,Business ond Professions Code}.
OWNER �e AIIdEII GPO
❑ I,as owner of ihe property,am exclusively coniracting
wi�h licensed contractors ro construd the projec�(Seo- ��� 107�+ Parkview IJrive ��l
tion 7044,Business and Rofessione Code). A��RESS
CONSTRUCfION LENDING AGENCY CITY cpying� T���N�� g18-967-95�+1
, I hereby affirm Ihot there is a construclion lending agency for �
the performance of ihe work for which this permi�is issued �ONTRACTOR��0 �� IgC•
(Sec.3097.Civ.C.). _.. _.. . .. .
nooRess 1232 W. 9th Street
Lender':Name
Lender'sAddress CITY �plAnd TEL.NO 714-981-4$Ol (
STATE UC.
I cerlify that I have read this opplication and state ihat the u�Ns�No. 380543 C1a55 C—`��
above information is correct.1 agree to comply wirh all County
ordinances and Stote laws relating to b�ilding construction, �
and he�eby outhorize representatives of this County ta enter
upon t�bo�ye-mantion �properry for in-peCtia=purpases. SEE REVERSE fOR EXPLANATORY LANGUAGE
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i�n � i
Signature of Applicant or Agenr Date I
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