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HomeMy Public PortalAbout4857 ARDEN DR_Mechanical__ WORKERS'COMPENSATION DECLARATIONA (� affirm that�I Piave ,a certificate of consent to self APPLICATION FOR PERMIT L.,.,, or a certificate of VC:_,kers' Compensation Insurance, a cf(Sec. 3800, Lab. C.) 76A364C HEATING - VENTILATINGVENTILATING - AIR CONDITIONING P�},�1� yo_ �-(Fy� o (251 µ V Z5� CE-818(REV. 10/81) Policy No. Company State Comp. Certified copy is hereby furnished. Ins. Fund COUNTY OF LOS-ANGELES BUILDING AND SAFETY i Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion department. Master HeatingADDRESS 4$57 Arden Drive �} (PRINT OR TYPE ONLY) Date 12 $7 pplican A Co' LOCALITY Temple Cit NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMP O E NEAREST COMPENSATION INSURANCE CROSS ST. Lower Azusa (This section need not be completed if ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY the work involved by _ (y/ the permit is for one hundred dollars ($100)or less.) AIR HANDLING UNIT, CFM og� I certify that in the performance of the work for which this ✓� V permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. BOILER, BTU K 5APPROVALS DATE INSPE OR'S SIGNATURE Date Applicant 1 COMPRESSOR, BTU �M 10 �� ROUGH /i NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL -$ Exemption, you should become subject to the Workers' Compensation provisions of the Labor.Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU XX GGF}yY 10 00 LICENSED CONTRACTORS DECLARATION FLOOR BTU UUl/! I hereby affirm that I.am licensed under provisions of Chapter'9HEATER: SUSPENDED UNIT L (commencing with Section 7000) of Division 3 of the Business WAL � and Professions Code, and my license is in full force and effect. License Number 2115$9 Lic. Class C20 eOa Master Heating $/12/8709 Contractor & A] Y' r,OnC'1. Date 0 ❑ I am exempt under Sec. UJ Plan check fee C B.&P.C. for this reason Date: 10 0 PERMIT ISSUING FEE $ Signature TOTAL FEE 0 0 OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License , .2 7 814,A Law for the following reason (Section 7031.5, Business and NAME Professions Code): ADDRESS o 0 0'o o ❑ I, as owner of the property, or my employees with wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section CITY TEL. NO. . 7044, Business and Professions Code). ( © 3 Q 5,0 OWNER cantina Cretarolo ❑ I, as owner of the property, am exclusively contracting o o io 3 Q 5:0 v with licensed contractors to construct the project (Sec- MAIL = tion 7044, Business and Professions Code). ADDRESSI,.$57 Arden Drive -87 CONSTRUCTION LENDING,AGENCY �} 0 O 7 I hereby affirm that there is a construction lending agency for CITYTem le Cit 917$0 L' NO.444-5304 the performance of the work for which this permit is issued CONTRACTOR Master Heat in & A C Co. ® . (Sec. 30 , Civ. C..)• - - -ADDRESS 12846 Foothill Blvd. --. Lender's Name" Lender's Address CITY Sylmar, 91342 TEL. NO. $9$-1581 STATE 1 LIC. I certify that I have read this application and state that the LICENSE NO. 211589 CLASS -• 132O- _. above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter " upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE nature of Wrlicont or Agent Date