HomeMy Public PortalAbout9564 BISBY ST_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA 818C(2-80) APPLICATION FOR PER 1�1t}7
I hereby affirm that I have a certificate of consent to self
Inure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
■certifled copy thereof(Sec. 3800, Lab.C.)
Policy No. 431122,omPahy state fund
ElcCertitled copy B hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
E] Certified copy its flied with the county building Inspection BUILDING 9564 Bisb an/$ A llcant Air—Tro, R APPLICANT TO FILL IN y Street
Date
pp Inc.IriC. (PRINT OR TYPE ONLY) ADDRESS
LOCALITY e p e- i
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST }
(T1tla section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. d
by the permit is for one hundred doUara ($100) or lesa,) DISTRICT NO. PROCESSED BY 8
I certify that In the performance of the work for which this AIR HANDLING UNIT CFM cr
permit is issued, 1 shall not employ any person In any manner U
so as to become subject to the Workers' Compensation L %vs. BOILER BTU
4g, 000 1 /yo APPROVALS DATE IttsPECTOR'SSIONATURL? W
Date Applicant COMPRESSOR, BTU 4) ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM Z
Exemption, you should become subject to the Workers' FINAL —
Compensation provisions of the Labor Code, you must forth-
with comply with such proylglons or this parmit shall be EVAPORATIVE COOLER VALIDATION
deemed revoked. FURNAr
LICENSED CONTRACTORS DECLARATION FLOOR: FAUBTU ITY 10 00
I hereby affirm that I em Ileertaed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Bust- WALL
ness and Professions Code, and my License is In full force 4nd
License Number 258228 Lig.Class c10, 20,44 d o t ets ai 2 00
Contractor Air-Tro, IIF 3/16/84
ElI am exempt from the licensing requirements as I am e
licensed architect or ■.registered professional engineer Plan C11eck fee 25%of above.
acting in my professional capacity (Section 7051, Bur
Iness and Professions Code). PERMIT ISSUING FEE 1
Lte_or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT • surcharge
I hereby affirm that I am exempt from- the Contractrx's NAME 297 8 3 A
License Law for the following reason (Section 7031.5, Bust- # •'o o • •
ness and Professions Coda): ADDRESS
1, as owner of the property, will do the work and the
structure Is not intended or offered for sale (Section CITY TEL, NO. 2'-'-:5'1.5 0
7044, Business and Professions Code). ro'o'o tverz 1.Jr 0 cS5
1, as owner of the property, am exclusJy coutncting OWNER Gilbert Rolden
I_Jwith licensed coutractora to construct the project MAIL o 11 6'—8 4.
(Section 7044, Business and Professions Code). ADDRESS 4 Bi sb Street
CONSTRUCTION LENDIN6 AGENCY CITY Temple City TEL. NO, 575-0292
I hereby affirm that there is a construction lending agencyy
for the performance of the work for which this permit is CONTRACTOR Air—Tro, Inc.
Issued (,Sec. 3097,Civ.C.).
Lender.s Name ADDRESS 1630 S. Myrle Ave..
Lender's Address CITY Monrovia, Ca.TEI�. NO. 285-3175
1 oertify that I have read this Application and state that the STATELIC. e10, 20,4
above information is correct. I agree to Comply with ell County LICENSE 258228 CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives o-f this SEE REVERSE FOR EXPLANATORY LANGUAGE
,p,4nur
to ente Pon the ab -mention roperty for
8 P e Date