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Home My Public Portal About9439, 9441 BROADWAY_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C I here CE-818 (2.80) APPLICATION FOR PERMIT )' affirm that 1 have a' certificate Of consent to self insure, or a a:rtit irate of Workers'Compensation Insurance,or HEATING-VENTILATI NG-AIR CONDITIONING a certified copy thereof(See. 3800,Lab.C.) ' Policy No. BP10314A Company Calif. Ind.'Ins. Certified copy is hereby furnished. COUNTY OF LOS ANGELES. BUILDING AND SAFETY Certified copy i5 filed with the county building inspection Xn n-p ment. p FOR APPLICANT TO FILL IN BUILDING Da4e Applicant N�S I'-'C)lalllCal. SySteR4 (PRINT OR TYPE ONLY) ADDRESS LOCALITY / y CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE - NEAREST } (This section need not be completed if the work involvedABSORPTION UNIT, BTU— CROSS ST. 0. by the permit is for one hundred dollars ($100) or less.) DISTRIC�7. PRDCESSED By U 1 certify that in the performance of the work for which this AtFt HANDLING UNIT,CFM G CC permit is issued, 1 shall not employ anypersonin any manner J ' v O O so as to become subject to the Workers' Compensation Laws, BOILER BTU ♦- Date Applicenb 1 36;W0_ 10.00 APPROVALS DATE INSPECjOR's SIGNATURIj Lu COMPRESSOR,BTU ROUGH `_wry�� l �� - 0- NOTICE NOTICE TO APPLICANT: If,become 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 provisions or' this permit shall be EVAPORATIVE COOLER - VALIDATION deemed revoked. 1 X FURNACE: FAU— GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR: BTU-415,(B— 10.00 1 hereby affiim that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT 9 (commencing with Section 7000) of Division 3 of the Busi- WALL ness and Professions Code, and my license is in full force and effect. 9 Supplies 15.75 License Number 550156 Lie.Class C/� ��D�+ �,ryy�r��rT 1 Return 1.75 ContraciorNES_MMIANICAL_ Date 11-91_ I am exempt from the licensing requirements as 1 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 FEE $ ]� - Lie.or Reg.No. Date TOTAL FEE - HOME OWNER-BUILDER DECLARATION. PLAN CHECK APPLICANT ' I hereby affirm that 1 am exempt from- the Contractor's NAME License Law for the followingreason (Section 7031.5, Busi. -_ ness and Professions Code): ADDRESS ' ' El 1, as Owner of the property, will do the work and the structure is not intended or offered for sale (Section CITY TEL. NO. 7044;Business and Professions Code). F1 I, as owner of the property, am exclusively contracting OWNER 1?,rQ311way HUB25 Limited Ltd. I E!i3 with licensed contractors to construct the project MAIL 150 N Santa Anita #470 - 'j-f''n < :�+- ,�! (Section 7044, Business and Professions Code). ADDRESS _ --3-q}a, 00 CONSTRUCTION LENDING AGIn len CITY TEL NO. - 1 hereby affirm That there is a construction lending agency -ATCad3a r-CA' -for the performance of the work for which this permit is CONTRACTOR N11; S. Medlanical S Stems issued (Sec. 3097,Civ.C.). -y. Lender's Name _ ADDRESS 518 S. Vermnt Ave. CC ender's Address CITY TEL. NO certify that I have read this application and state that theGlendora-Ca._91740. 914-56% . __ STATE LIC. _ 1 AIM Q'17 above information is correct. 1 agree to comply with all County LICENSE NO. 550156 CLASS C 20 ri inances and State laws regulating Heating. Ventilating and 'r Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE ;utry to enter upon the above-mentioned property for - ection purposes. -� nature of Permittee Date VIORKE S'COMPENSATION DECLARATION 76A318 APPLICATION Ip p y N p PERMIT E pal y I herrby affirm that 1 have o certificate of consent to self CE BiH (2-80) P'�Y� I'L IC P9 1 I O 1 tl I-O Y'i r IG IDg I 1 insure, or a certificate of Workers'Compensation Insurance,or - HEATING-VENT ILATI NG-AIR CONDITIONING a certififd copy thereof(Sec. 3800,Lab.C.) BP1-314A. Calif. Ind. InS. Policy No. ompany - COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished. - Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING -departm=nt ADDRESS 9441 Broadx_ T le Cit Date 4-17-89 Applicant NEE ��1C21 SyStHRa S (PRINT OR TYPE ONLY) yf � y LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO, TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE - NEAREST (This section need not be completed If the work i...lved ABSORPTION UNIT, BTU CROSS ST. R 6y the permit is for One hundred dollars ($100) or less.) DISTRICT NO. PROCESSED By O Lcertify that in the performance of the work for which this AIR HANDLING UNIT,CFM_ ,\ / (�n n permit is issued, I shall not employ any person in any manner - . V b �--li��-'{ so as to become subject to the Workers' Compensation Laws. BOILE,R, BTU O APPROVALS DATE INSPECTO R's SIGNATURE U Date Applicant ' 1 COMPRESSOR,BTU 42,00010.� ROUGH _ d NOTICE TO APPLICANT: If, after making this Certificate of FINAL VENTILATION SYSTEM 1 iQ Exemption, you should become subject to the Workers' /O�� y UG Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit-shall be deemed revoked- FURNACE:. FALX— r,RAVITV LICENSED CONTRACTORS DECLARATION 1 FLOOR: BTU-75,000 .10.E I hereby affirm that 1 am licensed under provisions of Chapter HEATER: SUSPENDED UNIT 9 (commencing with Section 7000) of Division 3 of the Busi- WALL ness and Professions Code, and my license is in full force and effect- . Plj License Number' 550156 Lic.Class • G 26 - 12 SU 21.00 1125 Return 1.75 Contractor NES %chani.cal SystErs EXP 11-91 1 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- PERMIT ISSUING FEE $ ' iness and Professions Code). 10.50 Lic.or Reg.Na. Date TOTAL FEE 53,25 HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 1 -hereby affirm that 1 am exempt from- the Contractor's NAME License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): ADDRESS 1, as owner of the property, will do the work and'the CITY TEL. NO. - structure is not intended or offered for sale (Section - . - 5'.25 7044, Business and Professions Code). _ -'❑ I, as owner of the property. am exclusively contracting OWNER Broaskxy ornas i.im,ted Ltd. T7: " with licensed contractors to construct the . project MAIL 150 N. N.,.Santa Anita # 470 - l i' 5 '-V_ c3 n = ' (Section 7044. Business and Professions Code). ADDRESS _ - CONSTRUCTION LENDING AGENCY CITY Arcadia TEL.NO. - -U 1 hereby affirm that there is a construction leading agency for the performance of the work for which this permit is CONTRA- CTOR N.E.S. BLC1ar7Cal S StERS issued (Sea3097lry •_i '-- Civ.C-). ' Lenders Name ADDRESS 518 S.VEmmnt Ave, , : nY„1 Esq Lender's Address '/ Z. CITU Glendora Ca. 91740 TEL.No. q14 569(9 - ��-:- f r„Y �,,i� I certify that I have read this application and state that the STATE rjj(j1 j LIC. (,' •• - AI above information is correct.I agree to comply with all County LICENSE NO. CLASS , ordinances and State laws regulating Heating. Ventilating and Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE County to enter upon the above-mentioned property for i,...ectiun purposes- Signature of Permittee Date