HomeMy Public PortalAbout9966 BOGUE ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 20 6DPW9,69,
76A36APPLICATION FOR PERMIT LIME GREEN
76A364C
I hereby affirm that'l have a certificate of consent to self Insure,
or a certificate of Worker,'s Compensation Insurance, or a certified HEATING - VENTILATING -•AIR CONDITIONING
Copy thereof(Sec 3800'Lab. C) I�rA,
Policy No.�'-r 9 9�?5�ompanR 0 I I h �1�o �
❑ � COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUI ING AND SAFETY DIV.
Certified copy is hereby furnished.
® Certified copy is filed with a co U11 s ctlon FOR APPLICANT TO FILL IN BUILDING
department.' K (PRINT OR TYPE ONLY) ADDRESS
Date-7 5 TQ..T�—Applica NO TYPE OF APPLIANCE OR EQUIPMENT FEE I L°cALITY T e m p 1 City
CERTIFICATE OF EX P ION FROM WORT NEAREST
COMPENS T WINSURANCE CROSS S-B�a 1 d W 1 •
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be c pleted if the wo nvolved by the - MAP BOOK PAGEPARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO PROCESSED BY .
I certify that in the performance of the work for which this permit
is issued, I shall not employ an person in an manner so as to
P Y Y P Y BOILER,BTU Y/
become subject to the Workers' Compensation.Laws.
COMPRESSOR,BTU
• � APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant t VENTILATION SYSTEM'
NOTICE TO APPLICANT If, after making this Certificate.of ROUGH
Exemption,you should become Subject to the'Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor,Code, you must forthwith comply with such FINAL -
provisions or this permit shall be deemed revoked." FURNACE: FAU GRAVITY ALIDATION ,
LICENSEb'CONTRACTORS DECLARATION FLOOR = BTU 1 5 . 00
I hereby affirm that'I am licensed under provisions of Chapter 9 SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business and . HEATER, WALL `
Professions'Code,and my license is in full force and effect. :
Ase-Nur cClass C-2 0
a.
Date 7/15/91 O
U
Plan check fee
r ec. - Q
B&P C for thl reason PERMIT ISSUING FEE $ 1 5 U
Date: TOTAL FEE L45-1. 00 d
Signature - PLAN CHECK-APPLICANY
OWNER-BUILDER DECLARATION -?
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions
Code):. - ADDRESS ,Ai•{• •r-
I;'as owner,of the property,,or my employees with wages
'i•.':is°=
as their sole compensation, will do the work and the CITY TEL NO: --
structure is not intended or offered for sale (Section 7044,
Business and Professions Code) OWNERc, ni=,li` _ -�o
Ias owner"of'the property, am exclusively contracting - Ann RP is`I '- -�._s m t✓
MAIL
with licensed,contractors to.construct the project (Sec- ADDRESS9 9 6 6 Bogue Street IL_:T `'-`•F I=j
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY Temple Cit y TEL'NO 285-9928 '- ! Nt��,
I hereby affirm that,there is a construction lending agency for CONTRACTOR
the parformance'of the work for which this permit is issued g r ant Heating & A/C Inc . "
(Sec 3097, Civ.G) , c IJIr L l,. s
ADDREss. .1350 East Las Tunas Drive
1
Lender's Name
CITY San Gabriel TEL No' 286-1141
Lender's Address STATE LIC.
NO
certify that I have read this application and state that the above LICENSE CLASS C_
infW
gree to comply with all County ordinances _
anbuilding construction,'and hereby authorize
repounty to enter u n the above-mentioned
prurposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
7Z15/g1
SI AT ,u APPLICANT OR T- DATE