HomeMy Public PortalAbout6110 AVON AVE_Mechanical_3/25/1996_furnace and compressor r
WORKER I have
COMPENSATION
ate DECLARATIof consent to 20 004676A364 DPW 9/89 APPLICATION FOR PERMIT LIME GREEN
76A364C
I hereby affirm that I have a certificate of consent to self Insure
or a certificate of Worker s Compensation Insurance or a certified IV HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec 3800 Lab C) x -
Policy No G9611130 pany Cal Comp COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
0 Certified copy Is hereby furnished
El 111 BUILDING
�.Ified c Is filed with qhcou I dl I ection FOR APPLICANT TO FILL IN ADDRESS 6110 AVonCme (PRINT OR TYPE ONLY)2 'Dat AppllcNO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALIT1TemP1e City,
CERTIFICATE OF EXEX�ON
N FROM WORT S + CROSS NEAREST
Lo
r COMPENSASURANCE n
ABSORPTION UNIT BTU ASSESSOR t �
(This section need not be completed if the work Involved by the MAP BOOK n PAGE PARCEL
permit Is for one hundred dollars($100)or less) AIR HANDLING UNIT CFM "
DISTRICT NO PROCESSED BY 1
I certify that In the performance of the work for which this permit ,
Is Issued I shall not employ any person In any manner so as to BOILER BTU {
become subject to the Workers Compensation Laws
COMPRESSOR BTU G�
4 APPROVALS DATE INSPECTOR S SIGNATURE
Date Applicant VENTILATION SYSTEM b
NOTICE TO APPLICANT If after making this Certificate of ROUGH L
Exemption you should become subject to the Workers Compensation EVAPORATIVE COOLER y �/
provisions of the Labor Code you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked FURNACE FAU �Y ITY r
LICENSED CONTRACTORS DECLARATION 1 FLOOR BTU /J (f/ VALIDATION ' S
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL r
Professions Code and my licensees In full force and effect p
�,-- - -, furnace and
L,cens um r LIc Class C-20 ad air conditioning 4— - ACLTeg
3303 —CL
>-
80e50
Contra Date 1 ITEMS
InPe.empt e ec
Plan check fee TOTAL
c30 m 5Ci 0
B 8P C for this reason � PERMIT ISSUING FEE$ CHECK
80.El0U
Date TOTAL FEE �� �' CHANGE .000-
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Signature PLAN CHECK APPLICANT s
OWNER BUILDER DECLARATION Z
I hereby affirm that I am exempt from the Contractors License Law NAME ' lJLf00- 1 3/29/96for the following reason (Section 7031 5 Business and Professions tt
Code) / ADDRESS AM 9.00
F1 I as owner of the property or my employees with wages
as their sole compensation will do the work and the CITY n p TEL NO 'r4
structure Is not Intended or offered for sale (Section 7044
Business and Professions Code) OWNER MrS. James Malone m
I as owner of the property am exclusively contracting MAIL z
with licensed contractors to construct the project (Sec ADDRESS 6110 Avon
tion 7044 Business and Professions Code)
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c
hereby affirm that there is a construction lending agency for -"
the performance of the work for which this permit Is Issued CONTRACTOR Bryant Htg & A/C Inc
(Sec 3097 Civ C) Poo
ADDRESS � ._
r � � 1350 E. Las Tunas Drive ,
Lender s Name i
CITY San Gabriel TEL`No 286-1141
Lender s AddressTELIC
t
I certify that I have read this application and state that the above LCENSE NO 221751 + CLASS C-2U
informatio- Is correct I agree to comply with all County ordinances i
and State,laws elating t� ildmg construction and hereby authorize
represe nta s of t is Cdunty to enter upon th bov mentlone
property Inspe poses �� �j7� SEE REVERSE FOR EXPLANATORY LANGUAGE _ w_
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I� r
,,SIGNATURE OF APPLICANT ORA T DATE
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