HomeMy Public PortalAbout4509TEMPLE CITY BLVD_Mechanical (2) WOR KI RS COMPFNSATION DI CLAR A:ION CE 81C APPLICATION FOR PERMIT
I hereby affirm that I hase a certificate of consent to self CE 818 (2 80) /7
insure or a certificatethereof
( Workers Lab C sawn Insurance or HEATING-VENTILATING-AIR CONDITIONING U
a certified copy[hereof(Sec 3800 Lab C ) -
Pollcy No 496801 Company State Comp. Fund
❑ amfiea copy Is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
® Certified copy Is filed /_ �
Lount) ' Idmg Inspection
depar Q�/f f FOR AP TORT PEO FILL IN BUILDING
Dat e._.� /a'-' Apphca (PRINT OR TYPE ON LV) ADDRESS 09 Temple-C-3 R1 V
CERTIFICATE OI EXN rROM WORKLRS NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY Temple City
COMPLNSA I ION INSURANCL NEAREST T
CROSS ST i d
(Thud section need not be completed If the work involved ABSORPTION UNIT BTU—
by
TU by the permit is for one hundred dollars (SI00) OT less) DISTRICT NO PROCESS Der C.)
I certify that in the performance of the work for which this AIR HANDLING UNIT CFM { Q CC
permit 6 Issued 1 shall not cmpluy any person in any manner - J v � '/ O
sn as t0 be n C SUble Ct to the Wr [er5 Co enSJ tion Laws BOILER RTU /WPgOV ALS DATE INSPECTOR SSIGNATURE L)
Date _ Applicant_ 4 COMPRESSOR BTUA2_ 00 �'
ROUGH II��7 8 c, U)
NOTI E TO APPLICANT after making this Certificate of VENTILATION SYSTEMZ
Lxemption you should Benin, subject to the Workers 6 6.0- FINAL
Compensation provisions of the Labor Code you must forth I
with comply with such provisions or this permit shall`beEVAPORATIVE COOLER � VALIDATION
deemed revoked
FURNACE FAU_ GRAVITY—
LICENSED CONTRACTORS DECLARATION
FLOOR BTU
1 hereby affirm that 1 am licensed under priwmims of Chapter HEATER SUSPENDED UNIT V
9 (commencing with Sellion 7000) of Division 3 of the Bust WALL
ness and Professions Code and my license is In full force and
effect
LILAMse Numbe 396569 La Class C-20
Contractor _� Date
❑ 1 arK exempt from the licensing requirements as I am a
Ilcensed architect or a registered professional engineer Plan Check fee 25%of above
acting In my professional capacity (Section 7051 Bus
mess and Professions Code) PERMIT ISSUING FEE S 8 . 50
La or Reg No Date TOTAL FEE
HOME OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that i am exempt from the Contractors NAME -
License Law for the following reason (Section 7031 5 Buss
ties,and Professions Cod-) ADDRESS
I as uwnu of the property will do the work and the CITY TEL NO ;F'7 5 7 8 Q
(
strueturc is not intended or offered for sale Section
7044 Business and Professions Code) #a0 s0 V-:0,8
❑ 1 as Owner of the property am exclusively contracting OWNER Jayco Acceptance COT 2`• 1 .5850
.with licensed contractors to construct the project MAIL - }
(Section 7044 Busmen,and Profu,mns Code) ADORES596O—LOWer_A7usa_Ro t I
CONSTRUCTION LENDING AGENCY CITY Temple City TEL No 443-4437 a• 1 '5& 5,0,E
I hereby affirm that then Is a construction lending agency 1) 1 '5—8 2
for the performancL of the work for which this permit ¢ CONTRACTOR COUnty Heating br A/C In '
Issued (Sec 3097 Cry C )
Lenders Name ADDRESS
515__5_. Sunkist Sul
Lender s Address - CITY TEL NO - -
31-53.00
I certifythat I have read this application and state that the Anaheim 9
abuse Information is correct 1 agree to comply with all County LICENSE NO 396569 - C ASS C-20
ordmances and Sta% laws reguluting Heating Ventilating and
Air Conditioning and hereby authorize representatoes of this SEE REVERSE 1 OR EXPLANATORY LANGUAGE
County to enter up o the abose mention,d property for
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