HomeMy Public PortalAbout9844 BROADWAY_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby aff'Irm that I have acertifi<ate of consent to self �V�
l� insure, or a certificate of Workers'Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.)
CE-81 B(REV. 10/81)
Policy No.PC97S9S7CompanyR PpIIh LiG Inde Mnity '
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
® .Certified copy is filed with the county buil ing inspec- FOR APPLICANT TO FILL IN BUILDING
tion deportment. ADDRESS 9844 East Broadway
Qf (PRINT OR TYPE ONLY) LOCALITY Temple Cit
Date 10120/87Applicant P Y
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTIO � ROM WORK NEAREST
COMPENSATIONI SURANCE CROSS ST. 'Tem le City Blvd
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NQ PROCESSED BY
the permit is for one hundred dollars ($100) or less.) AIR HANDLING UNIT, CFM
I certify that in the performance of the work for which this -
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU n APPROVALS DATE IN57CTOR'S SIGNATURE
Date Applicant COMPRESSOR, BTU 49PA I ROUGH
NOTICE TO APPLICANT: If, aftermakingthis Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' IV T
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAUGRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR
1 hereby affirm that am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT—
(commencing
USPENDED UNIT_(commencing with Section 7000) of Division 3 of the Business - WALL
and Professions Code, and my license is in full force and effect. d I'TS , y
O
Licn e m Lic Class' s D V
K
Comet ctor OCIle
I am ex pt under Sec. W
Plan check fee - d
N
B.BP.C. for this reason' Z
Date: PERMIT ISSUING FEE $ /O 5-C # 8 S.8
Signature TOTAL FEE _ s sb -
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I ° ° 5,� 5 0
I hereby affirm that I am exempt from the Contractor's License
Law for the f6llowing reason (Section 7031.5, Business and NAME
Professions Code): '( 2,;� Q'—9 9
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation, will do the work and
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL '
tion 7044, Business and Professions Code). . ADDRESS
CONSTRUCTION LENDING AGENCY - CITY Temple City, CA TEL' NO 285-6678
1 hereby affirm that there is a construction lending agency for -the performcm6e of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.). Br ant Heating and Air Conditionin PC. _
Lender's Name ADDRESS 1350 E. Las Tunas Drive - - - -
Lender's Address - CITY San Gabriel, CA 9177&L-NO286-1141 — -
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. 221751 CLASS C-20
above information is correct. I agree to comply with all County -
ordinances and State laws relating to building construction, -
arfd e eyYY��o ut I e representatives of this County to enter
6 - ntioned grope for inspel<tio purpose . 7 SEE REVERSE FOR EXPLANATORY LANGUAGE ,
gnwure of Appllcon or gem Cl Dole / -