HomeMy Public PortalAbout5043ALESSANDRO AVE_Mechanical 7?A364C
WORKERS'COMPENSATION DECLARATION CE-818(2.80) Q p pUC A T S O N F O R p C R M ff
I hereby affirm gnat I have a certificate of c.onsert tC, self-
insure, or a certificate of Workers'Compensation-Irfsuratice,r, I�EQTB(r1�v-Qf[�Sf�T ILL1�04�14;s-G1VG�t �o®fel®O7O0V�f011�(�
a certified copy thereof(Set. 3800,Lab.C.)
189eyWPo.483405-lornpany Fremont Indemnity_
❑ Certified copy is hereby furnished. jl j� '� COUNTY OF LOS ANGELES BUILDING AND SAFETY
1x13 Certified copy is filed with the county building inspection FOR APPLICANT TO F1l I_IN BUILDING
department. ADDRESS 5043 Alessandro Ave.
Date 7!1_.90_ ApplicantN_..E-.S. Mechanical Systems (PRINT OR TYPE ONLY)
CERTIFICATE OF EXEMPTION FROM WORKERS'
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY Temple City, CA 91780
COMPENSATION INSURANCE NEAREST
CROSS ST. MAP # 38 B-3
('Phis Section need not be completed if the work 'involved ABSORPTION UNIT, BTU CL
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSED BY
' O U
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
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 AT i '-^ECTOR'S SIGNATURE �
Date Applicant 1 COMPRESSOR,BTU 421--0 12'00 ROUGH ?]Iam
_ LU
a
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL 2
Exemption, you should become subject to the Workers' _
Compensation provisions of the Labor Code,you must forth- I EVAPORATIVE COOLER I TI ni
with comply with such provisions or this permit shall be { _
deemed revoked. FURNACE: FAUXX GRAVITY
LICENSED CONTRACTORS DEGLAR ATION 1 FLOORBTU-7-5-000- 12.00
I hereby affirm that I am licensed under provisions of Chapter I HEATER: SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Busi- i WALL
ness and Professions Code, and my license is in full force and
effect. �� 10 Outlets @ $2.00 each. 20.00
License Number 550156 Lic.Class C 20
RE5,. Mechanical Systemse. 11-90 1 Inlet �? $2.00 each. 2.00
a_:�.
I am exempt from the licensing. requirements as I am a .
licensed architect or a registered professional engineer �'Plan check fee 25%of above. - -
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING EEE $ 13.00
Lic.or Reg.No. Date T®TAB_.FEE AC•1rT.s
...59.;QQ.. ..._ 3301 59.1130
HOME OWNER-BUILDER DECLARATION , PLAN CHECK APPLICANT
1 ITEMS
I hereby-affirm that I am exempt from- the Contractor's ; NAMEs �
License Law for the following reason (Section 7031.5, Busi- TOTAL
ness and Professions Code): I ADDRESS RElwdv 59.010
❑ 1, as owner of the property, will do the work and the CITY TEL. NO. CHANGE .00
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
OWNER William Chen
❑ [,.as oN}ner of the Property,. am exclusively contracting g 4-f�f,n t,�,t�f�t -. +�•� 1
with licensed contractors to construct the project MAIL 0000_120001 3/28/91
(Section 7044, Business and Professioas Code). ADDRESS 5043 Alessandro CITTEL,NO. �ce A�i .1U
CONSTRUCTION LENDING AGENCY not aVall_.-
I hereby affirm that there is a construction lending agency Y Temple City
for the performance of the work for which this permit is CONTRACTOR
issued-(Sec. 3097,Civ.C.). iV.E•S._Mechan Cal_S_y_stems
Lender's Name ADDRESS
518 S. Vermont Ave.
Lender's Address ESTATE
TEL.NO.
l.end.ora 91.740 8.1.8-9.124_569.6
I certify that I have read this application and state that the LIC.above information is correct.I agree to comply with all County E NO 550156 CLASS C 20
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County toenter up-n the above-mentioned property for
Sp
ect"' purposes.
� 3-26-90
`Signature of Permittee CCC Date