HomeMy Public PortalAbout10714 ARROWOOD ST_Mechanical_8/1/1980_compressor, furnace 76A364C '\
WORKERS'CUMi'ENSATION'DECLARATION CE-818 (�Z 80) (nl I� P L� C AT i OO N FOR I�E R UGIT T
I hereby of", i"that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,of "
HEATING AEL
V EP-"T IL.ATING-Al li '` �''" '^
a certified copy thereof(Sec. 3800,Lab.C-) v va.�ENING
Policy No. Company
Certified copy is hereby furnished. COUNTY OF LO � LDING AND SAFETY
Q Certified copy is filed with the county buildinginspection. FOR APPLICANT"TO FILL IN' BUILDING ! `�
department. ADDRESS
Date Applicant (PRINT OR TYPE ONLY)
LOCALITY
�4
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR-EQUIPMENT 'FEEit_�� _
COMPENSATION INSURANCE NEAREST �l�y
CROSS ST. f--ySCCG1�"�Lf O/U. �i��' }
(This section need not be completed if the work.Involved ABSORPTION UNIT, BTU �� •• -- — t1
by the 'permit is•for one hundred dollars ($100) or less.) DISTRICT NO. Pao r v O
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 Wnrkers' Cor pen.,pion Los ISOILER, BTU
�Q[ �eep7 APPROVALS DATE INSPECTOR'S SIGN'. ,tE U
Dater "C Applicant _ __ _ _ _ COMPRESSOR,BTU �0I po ROUGH d
NOTICE TO APPLICANT: If., after making this Certificate of VENTILATION SYSTEMto
Exemption, you should becom. e subject *to the Workers' FINAL JZ^/ –� Z
Compensation provisions-of the Labor.Code.,,you must forth- EVAPORATIVE COOLE1.R VALIDATION
with comply with such provisions or this-permit shall be
deemed revoked. �(� 1 ��� /f�J�
FURNACE: FRU_ GRAVITY Q V�
LICENSED CONTRACTORS DECLARATION ) FLOOR; BT U__�z�t_f?O_�D—
I hereby affirm.that Lam licensed under provisions of Chapter HEATER: SUSPENDED UNIT.
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
hess and,Professions Code, and my.license is in full force and
effect."• :.
License Number 30Z :��C70Lic.Class'
•Contractor�_1.2,��EC'l�Tr�s Q/�,g O - _ . +
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 705,1, Bus-
iness and Professions Code). PERMIT ISSUING FEE
Lic.or Reg.No. Date TOTALFEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from- the Contractor's NAME
License Law for the followttng reason (Section 7031.5, Busi-
ness and Professions Code):', ADDRESS
Q •I, as,owner of the property, will do the work and the
strgcturej'is not mfiended or"offered for-sale (_Section CITY C TEL. NO
7044, Business and-Professions Code).
❑ OWNER L9 ,I �5-1;:8 A
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the projectMAIL #�o.lo o;o.(G.�
(Section 7044,.Business and Professions Code). ADDRESS • 0 ,
CONSTRUCTION LENDING AGENCY CITY TEL.-NO. 1,o-0 2'7,0.0
I hereby affirm.that there is a construction lending agency
for the performance.of the-work for"_which.this permit is CONTRACTOR ° ° ° 2s7, 0;c�
issued(Sec.. 3097,'Civ,C.). 9 �F �-� L� - 4N
Lender's Name ADDRESS u�7�lL� •EG[r� O S.O �' Pf 0
Lender's Address CITY �T_� . 7 TEL.NO. 6
1 certify that I have read.this application and .state that the STATE - q r LIC.
above information is correct-I agree to comply with all County LICENSE NO. 3 GG oG CLASS <�:,-C
ordinances and'State'laws regulating Heating, Ventilating and
Air Conditioning, an;(hereby authorize representatives of this, SEE REVERSE FOR EXPLANATORY LANGUAGE
County to ente, upon the above-me .ioned property for
ion pp es.
Signature of Permittee Date