HomeMy Public PortalAbout10103 BOGUE ST_Mechanical_12/23/1985 ' W6RKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
hereby affirm that I have a certificate of consent to self
tiinsure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
ora e tified copy thereof LLSec 3800, Lab C ) 76_818
6g��79 GA. STATE-FUND CE
-818(REV. 1oielj #40665
Policy No Company
X Certified copy is hereby,furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department ADDRESS 10103 Boque Avenue
(PRINT OR TYPE ONLY)
Date 7—��_�,�, Applicant E., L. PAYNE CO LOCALITY Temple City
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST Baldwin Avenue
ED
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO PROLES
the permit is for one hundred dollars(;100)or less.) t O
AIR HANDLING UNIT, CFM
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 APPROVALS DATE 5 TOR'S SIGNAT E
Date Applicant COMPRESSOR, BTU 10 00 ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL ill
Exemption, you should become subject to the Workers' _
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU X GR VIj,Y
LICENSED CONTRACTORS DECLARATION 1 FLOOR BTU ' V v0T— 10 00 �I
hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED—UNIT—
'(commencing
USPENDED UNIT'(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force-and effect.
License Number ' 120228 Lic Class 0-990
OC
Contractor E• L
PAYNE Date 7-9-85 O
f—
❑ I am exempt under Sec. LU
Plan check fee
B.&P C for this reason PERMIT ISSUING FEE'$
Signature ;22 4'7,6 Z
Date: 0 0 �$ 00000 �
TOTAL FEE 30 0 0
50 3O,5 0
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT =
j hereby affirm that I am exempt from the Contractor's License , 0 a °0 v
Law for the following reason (Section 7031.5, Business and NAME
Professions Code)
❑ I, as owner of the property, or my employees with ADDRESS
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 Profession's Code)
El1, as owner of the property, am exclusively contracting OWNER Mr. and .Mrs. Chung Wong
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code) ADDRESS 10103 .Bo ue Avenue
CONSTRUCTION LENDING AGENCY CITY Temple Cit TEL No 445.-3662
j hereby affirm that there is a construction lending agency for loop
thPAYNE COMPANY
(Sec. 3097, Civ. C.)e performance of the work for which this permit is issued CONTRACTOR E. L.
Lender's Name -
ADDRESS - 14823 Ca f i fa Street
Lender's Address CITY Van Nuys TEL NO , 793-1131
STATE LIC C-20
I certify that I have read this application and state that the LICENSE NO 1 20228 CLASS
above information is correct. I agree to comply with all County
ordinances and State jaws 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
7-9_85
Signature of Applicant or Agent Date
C