HomeMy WebLinkAbout1687A • WORKERS'COMPENSATION�ECLARATION App��CATlON FOR PERMIT �
I hereby affirm that I have a certificate of consent ta self
jnsura,or a certifiwte of Warkers Comperuation Insurance, ���� HEATtNG - YENTILATING - AtR CONDITI�NING
or a certified copy thereof(Sec.3800,Lab.C.) �_818(REV.10/81�
P❑ollty No.PWC 0506���Y Golden �'3�e ZI1S.
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
O Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUIIDING
tion deparimenf. ADORESS 6 •
��e 5-29-89 qPP���a��RauCho A1T� TIlC. (PRINT OR TYPE ONLY) ��G4111Y Dismond Bar �1tI'SC't� �2rj82
NO. TYPE OF APPLIANCE OR E�l11PMEN7 FEE
CERTIFICCOMPENSATION'�NSU AN EORKERS' Crt05s si.�i�� � JOb� S�T6
(This socllon nu�d nof b�eomplatad iF}iw work inrolred b� ABSOaFfION uNiT,eTu oistwK*No PROCESSE�BY
iho parmiT is for ono hundrod dallen(f100)D��elf.� q�R HANDLING UNIT,CFM 1 /1 ,(� 0.\���
I certify fhat in the performance ot fhe work for which this 1 v ���
permit is iss�ed,I shall not employ any person in any manner
so as to become subject to ihe Woikers'Compensation Laws. BOIIER,6TU qpPppyq�5 on� INSPECIOR'S SIGNATURE
1 COMPRESSOR,BTU ���� IO OO ROUGH
Date 4PPlicant '
�"�TICE TO ACPIICANT: If, af�er muking this Certificafe of vENTitATiquSVSiEM F�NAI z�ZZ'
� nption, you should become subject to the Workers'
..mpensation provisians of ihe Lobor Code,you must forth- EVAPORATIVE COOLER . VA���AT�QN
with comply with s�ch provisions or this permit sholl be
deemed revoked. 1 FURNACE: FAI��GPAVIW�� lo �
- �ICENSED CONTRACTORS DECtARATION F�OOR gT� UU�V
I bereby offirm thof I om li[ensed under provisions of CFwpter 9 HEATER: SUSPENDED UNIT_
(tommencing with Section 7000'of Division 3 0£the-8usiness " WA«
and Wofessions Code,and my licertse is in fui!fwce arxf effect. �
13 Registers @ 1.75 Ea 22 q5 �1 b c.7 n p
License Namber �R��Sli� lic Class `�-7�1 , � � =V (,!
h• • pL
ContractorRanrhn Air� TnrJ]a�e R—'�7—�Q ' � �y`7� 0 {
� U �
I am exempt under Sec. P�an checR fee � � ��- ' :-- d
B.BP.C.for�h�s reason pEkMIT ISSUING FEE; 10. 0 � � Z
Date: TOTAL PEF 53.25 �9:2 C—:;2 �
SignaWre
OWNER-BUILDER DECLARATION PL4N CHECK APPLICANi
t hereby affirm thot i am eaempt fram ihe Contracior's License �
Law for the follawing reason(Section 7031.5, Business and NAME
Professions Code):
� 1, as owner of the property, or my employees witb �DRE55 -
- wages as their sole compensation,wfll do the work and
the struc�ure is nm intended or offered for sale(Section CIN TEL NO.
7044,Business and Professions Code).
OWNER �e And.en Gro
❑ I,as owner of the property,am exclusively contracting
wl�h li[ensed contractors to mnstruct ihe projeU(Ser ppRE� 1�7 Parkviesr Ilrive �`��l
fion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY Cppj,pa� Te�.No. g1.g—g67-95�+
I hereby affirm that there is a construction lending agency for ,
fha perFormance of the work for which this permif is issued CONTRACTOR �C�(Q ATR Ij�j C.
(Sec.3097,Civ.C.). '
ADDRESS �-232 W. 9th Street
lender's Nama
citr Upland TE�.No. 714-981—�►80
Lender's Address
STATE p IIC.
I certify ihaf I have reod this applicofion ond stple that the LICENSE NO. 3005�3 C1A55 C-2�
above informalion is correct.1 agree to comply with oll Co�nty
ordinances and State laws relating ro building canstrudion, �
ond hereby outhorize representotives of this County�o enter
upon t (a va-memiongd p�oper�y for insp�tio=pur�oses. SEE REVERSE FOR EXPIANATORY IANGUAGE
I
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