HomeMy Public PortalAbout9840 BROADWAY_Mechanical__ W(7RKtRS'COMPENSATION DECLARATION APPLICATION
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I hereby,,�,ffirm that I.have a certificate of consent to self- APPLQ' ATION ICOR PERMIT
i iei.,e, or a certificate of Workers' Compensation Insurance, 7aAaeaC HEATING - VENTILATING - AIR CONDITIONING
or o certified copy tl"i (Sec. 3800, Lab. C.)
PolicyNPCE-818(REV. 10/81)
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nC975952 ComlRiel hlir Indemnity
Certified copy is hereby furnished. COUNTY OF LOS ANGELES .BUILDING AND SAFETY
Certified copy is filed wi th ccA\WOS'
inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS9840 E. Broadway
Date 10/21/8LAppli at LOCALITY, Temple Cit
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EX P N FR
NEAREST
COMPENS N INSU RANC 'CROSS ST.
ABSORPTION UNIT, BTU pISTRICI NO. PROCESSEp BY
(This section nerd not be completed II the by
the permit is for one hundred dollars e work
or less.)hi AIR HANDLING UNIT, CFM
certify that in the performance of the work for which this
. permit is issued, 1 shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INS CTOR'S SIGNA
Date Applicant 1 COMPRESSOR, BTU 48,000 _ IC 00 ROUGH �� IAN 4 4/1
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' .
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU�,C.Q AVITY
LICENSED CONTRACTORS DECLARATION 1 FLOOR Btu 10 00
I hereby affirm that I am licensed under provisions of Chapter 9SUSPENDED UNIT_
'(commencing with Section of Division 3 of the Business WALL }
and Professions Code,and myy tic HEATER:license is in full farce and effect. �
SU O
License um ILic. Closs D V
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Confrocrorie F
❑ xeIPlcn checkfee ZBPCPERMIT ISSUING FEE $
Date: pp
Signature TOTAL FEE48 UO
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OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License D
Low for the following reason (Section 7031.5, Business and NAME - 2 8 5 8i1 A
Professions Code): -
❑ I, as ownerofthe property, or my employees with ADDRESS #.e e • s s 8
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY TEL. NO. • o e lL 8
7044, Business and Professions Code). OWNER DENNIS O'LEARY .I 2'1 4-8
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL 9
tion 7044, Business and Professions Code). ADDRESS
840 Rrnndway
CONSTRUCTION LENDING AGENCY cl" Tem le Cit ' CA' ' TEL. NO 286-434
I hereby affirm that there is a construction lending agency for D
the performance of the work for which this permit is issued CONTRACTOR - ' - -
(Sec. 3097, Civ, C.). Bryant
Lender's Name ADDRESS 1350 E. Las Tunas Dr4ye. -
Lender's Address CITY San Gabriel TEL. NO 286-1141 - -
STATE LIC.
I certify that I have read this applicationand state that the LICENSE NO. - 221751 CLASS C-20
above information is correct. I agree to comply with all County
"IFantes and State laws relating to building construction,
and h es and outhori ' epresentntives of this County to enter - -
upon v toned property r inspection rposes SEE REVERSE FOR EXPLANATORY LANGUAGE.
gnoWre of Applicant or nl Dore - `