HomeMy Public PortalAbout9509 BROADWAY_Mechanical__ I :S;COMPENSATION DECLARATION 76A364C
II CE .818 (2-Bo) • APPLICATION FOR PERMIT
1' ;�creh3' � .'ftat I have e' certificate of consent to self
insure,ot a certificate of Workers'Com pensat ion Insurance,Or HEATING-VENTILATING-AIR CONDITIONING
I a certified copy thereof(Sec. 3800, Lab.C.)
IPo',cyNo._81.83_CompanY Fremont Ins. ,
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
QCertified is filed with the building inspection
x copy e county FOR APPLICANT TO FILL IN BUILDING
department. ADDRESS 9509 Broadway
Date 7-1.-9Olpplicant.N 'ES_Mechanical_SySt(Fms (PRINT OR TYPE ONLY -
LOCALITY Ternple City Ca. -
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EOUIPM ENT FEE
COMPENSATION.INSURANCE NEAREST Y
CROSS ST.
"
(This section need 00[ be completed If the WOtk involved ABSORPTION UNIT, BTU (L
by the permit is for one hundred dollars (SI00)'or less.) .. OISTRICTNO. PROCESSFOBy ,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 13 v Cr
so,as to become subject to the Workers' Compensation Laws.. BOILER,BTU
APPROVALS DATE I INSPEtr-R'S SIGNATV 4E U
Date - Applicant 1 COMPRESSOR, BTU-48-j000 1'0.00- ROUG)4 J y
NOTICE TO APPLICANT: If, after making this Certificate of �J�-/- �
Exemption, you should become Subject to the Workers' VENTILATION SYSTEM FINAL" / 0.
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: FAUX— GRAVITY_
LICENSED CONTRACTORS DECLARATION 1 FLOOR' BT D7S.�.000 1.0.00
I hereby affirm that 1 am licensed under provisions of Chapter HEATER; SUSPENDED UNIT.
9 (commencingwith Section 7000) of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and 22.75
effect. 13 Supplies
License Number 5501 S6.Lic.Class ' C 20
1 Return 1_05
Con IractNFS_MeCh.._SySt.Date 11-91
r -
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 $ 1-Q 50,
Lic.or Reg.No.__- � Date - ,. TOTAL FEE 55 00 - -
HOME OWNER-BUILDER DECLARATION
PLAN CHECK APPLICANT T
I hereby affirm that 1 am exempt from- the Contractor's NAME _ rg
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS ACCT �
i, as owner of theproperty, ��rr�II -'
n will re the work and the CITY .. TEL. NO. ,31,07
structure is not intended Or offered for sole (Section . , . . - � ��^
7044, Business"and Professions Code). I,. __ T•t�y� -... .
' OWNER
1, as owner of the property, am exclusively contracting Craig -Sue_Hunt TOTAL- 515�_OQ'
.. s. .... _r..
with licensed contractors to construct the project MAIL - M
(Section 7044, Business and Professions Code). - ADDRESS 9509 Broadway
CHECK,
E ` �sVtl.
CITY - TEL.NO. GHANA
CONSTRUCTION LENDING AGENCY TII['IPIIE CITY CA. .� __. HANGS
for they affirm that there is.a construction lending agency -issued
the performance of the work for which this permit is CONTRACTOR
N.E.S._Mechanical_S stems"-
issued 'Sec. 3e Cie.C.). 518 S. VErmont Ave. y -� QQQp-000l 7/18/89
Lender's Name- ADDRESS
Lender's Address CITY Glendora Ca 91740L.ND. 914 5696 4538 1. AM10:30
I certify that 1 have read•thisapplication and state that the STATE LIC.
.above information is Correct. I agree to comply with all County LICENSE 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 to enter upon the. above-mentioned property' for I
action purposes.
7-1.3-89_
Signature of Permittee Date ,