HomeMy Public PortalAbout10720 ARROWOOD ST_Mechanical__ WORKERS'COMPENSATION DECLARATION 75A364C n P P p, pC /,a �r�0(�p FOA
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I'hereby affirm that- I have a' certificate of consent.to self CE-818(2-80) W Ir Ifs L�U G�l U Ul U1C Ir LS IIS➢�%ll -"p
insure, or a certificate of Workers',Compensation Insurance,or " '
a certified copy thereof(Sec. 3800,Lab"C-) 6IfAhC9-!!(E�TI�AT'll�lCvrAllf3 ®G�I�I�i 1®(f�BbGii
Policy rB7 80 0_5'_Q9 _emont Inde it p- Co o' Y
Certified copy is hereby furnished. COIUftIl OF LOSANGELES BUILDING AND SAFETY
X Certified copy is filed with.t'.e*oi- ity buildir�' pP tion — • BUILPING
C dP FOOD APPLICAN TO FELL Ilv 10720 Arrowood Street
p rrer/t
Date 'T_T" 81Applicant_ (PRINT OR TYPE ONLY) ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS''
NO. TYPE.OF APPLIANCE OR EQUIPMENT FEE LOCALITY Temple CZty,,,' -
COMPENSATION INSURANCE NEAREST ,
(This section need' not be'completed;if the work involved. ABSORPTION UNIT;eTu CROSS ST. Persimmon
by the permit is for. one.hundred dollars ($100) or less.),, sTRI U
AI'R,HANDLING UNIT,CFM
DI �T NO.. =l' 'PRO'c35 8Y
I certify that in the performance. of.the.;work for which this �••.
permit is issued, I shall not.employ any,person in any manner "<
so as to become subject to the Workers' Compensation Laws. BOILER, BTU' AYt)aE U
APPROVALS DATE' INSPECTOR'SS
Uj
Date
Applicant,, COMPRESSOR,BTU ROUGH �� r Ic. N:.
NOTICE:TO APPLICANT,: If, after making this,Certificate of, VENTILAbON SYSTE�1 ` I Z_
Exemption, you should' become subject to the Workers' FINAL
Compensation provisions'of the Labor Code, you must forth- EVAPORATIVE COOLER AL•LEJATI�N'
with comply with such provisions or this .permit shan'be '
deemed revoked. FURNACE: _ FAU GRAVITY
y
LICENSED CONTRACTORS DECLARATION FLOOR:- BTU
I hereby affirm that 1 am licerfsed under provisions of Chapter HEATER: SUSPENDED' UNIT'
9.(commencing with Section 7000)of Division 3 of the Busi- 1` WALL '". 35,9'000 BTU (/
ness and Professions Code;and my license.is in full force and
'
effect:' / Cm20
License 41 -
c er_4_66 �F --1- Lic:Class- G
Contrac _ -_ ate_3�16/rJl
EI am exempt from'the licensing,requirements as I am a
licensed architect or a registered 'prcifessional'engirieer Plan Check fee 25%of above.
acting in my professional capacity (Section 7051, Bus•
iness and Professions,Code). 'P'ERMIT ISSUING FEE$
Lie.or Reg.No. Date:" TOTAL FEE.
1 r
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby 'affirm that,.I am exempt 'from-the Contractor's NAME
I:icense Law for the following reason (Section 7031.5,.Busi
ness and Professions1Code): �' -ADDRESS
I, as owner of the property, will do the work and the. x.4.4 Q 4 A
structure is not intended, or offered for sale (Section.' CITY TEL. NO.
7044,Business and Professions'Code)."
OWNER a •t,
I,as owner of the property, am exclusively contracting - `•' Blue_R�bbon_Bu11_ders
with. licensed contractors to construct the project MAIL 7 .7 1' ° °J i7
(Section 7044„Business and Professions Code). ADDRESS M, 1.0 0_w-O-Oli_S-tre.e:t
CITY TEL.NO. ° ° o ) 7 0 0'_v
CONSTRUCTION LENDING AGENCY Temple—Ga.ty
1 hereby affirm that there is a construction lending agency Q 2:3 `�
for the performance of the work for which this permit is CONTRACTOR
P p D m & A. Plumbing-9—Inc;
issued(Sec. 3097;Civ.C.).
Lender's Name ADDRESS' '
6.37 Eas_t_Manches-ter_ E=mF
Lender's Address CITY LOS Angeles TEL: NO. 751®7225
I certify that I have read this application and state that the STATE LIC.
above information'is correct.I agree to comply with all County LICENSE NO. CLASS
2:6.65_4_4 Go.2.0
ordinances and State laws regulating dating, Ventilating and
Air Condi.io i�g,and hereby.author'. representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County oe te" upon the ovF-.nen6oned properly for
inspect' n' x' p.s,
_ � i �i
Signature,,r'ermMee Date