HomeMy Public PortalAbout5938 BURTON AVE_Mechanical__ pp FOR
PERMIT
WORKERS'COMPENSATION DECLARATION P9���I�P'i�0®Irl r®tl'l Ir�Ylpp� ll II
• ' P'i LVA CI IS
I hereb�,I in that I have a certificate oflconsent to self
insurd, or a ceftificbte of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a'certified copy thereof (Sec. 3800, Lob. C.) 76A364C
„I CE.818(REV. 10/8I) '
Policy,t4o.Pr•QC1T'7S7 Company Republic; Ind. COUNTY OF.LOS.ANGELES BUILDING AND SAFETY
❑r Certified copy is hereby furnished.
Certified copy is filed with cou b ing inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS 5938 N. Burton
Date 5/77/,99 Applicant LOCALITY1 i>.•
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPT FROM W RS' NEAREST
COMPENSATIO NSURANC CROSS ST. Hermosa
DISI RICi NO. PROCESSED B
(This section need not be completed if the ark Involved by ABSORPTION UNIT, BTU
the permit is for one hundred dollars ($100)or less.)
1 certify that in the performance of the work for which this AIR HANDLING UNIT,CFM 51 V
permit is issued, I shall not employ any person in any manner '
so as to become subject to the ers cation La BOILER, BTU APPROVALS DATE INSPEC R's GNATURE
COMPRESSOR, BTU ROUGH
Date 5/22./89 Applicant
NOTICE TO APPLICANT: If, aft eking this rlif kale of VENTILATION SYSTEM FINAL
Exemption, you should bec a subject t e Workers' _ _
Compensation provisions of the Labor Code, ou must forth- EVAPORATIVE COOLER V LIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU VITY 77 (�
LICENSED CONTRACTORS DECLARATION 1 FLOOR BTU
'I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT_
'(commencing with Section 7000) of Division 3 of the Business - WALL
and Professions Code, and my license is in full force and effect. y
O
rUce *pl
Lic. Class C`20 adCd 1 .75/ea OV
r Sec d
Plan check fee
B.BP.C. for this reason' ' W
Date: PERMIT ISSUING FE .S Z
TOTAL FEE
Signature
OWNER-BUILDER DECLARATION _ PLAN CHECK APPLICANT I�`V/K-
I hereby affirm that I am exempt from the Contractor's License -
Low for the following reason (Section7031.5, Business and NAME s _
Professions Code):
❑ 1, as owner of the property, or my employees with ADDRESS ACGT.i
wages as their sole compensation,will do the work and CITY TEL. NO, ---- 3, 0]-- 44.SC1
the structure is not intended or offered for sale(Section ITEMS
7044, Business and Professions Code). OWNER ' 1'-ITEM kS
❑ 1, as owner of theproperty, om exclusively contracting 1�'Ir. BOhden ROst1V e
. Y 9 MAIL s
with licensed contractors to construct the project (Seo TOTAL 4�a• e � d
tion 7044, Business and Professions Code). ADDRESS 5938 North Burton CHECK 44.50
CONSTRUCTION LENDING AGENCY CITY San Gabriel TEL, NO. 286-7970 _ HSE 'r'r.�nJl
I hereby affirm that there is a construction lending agency for D "' -
the performance of the work for which this permit is issued CONTRACTOR Bryant Ht & A/C
(Sec. 3097, Civ. C.).
ADDRESS 1350 E. Las Tunas Drive - 0000'0041 6/ 5/89
Lender's Name
Lenders Address CITY San Gabriel TEL. NQ 286-1141 37083 1 fI112:16
STATE LIC.
I certify that I have read this application and state that the LICENSE No. 221751 CLASS CZO _
above information is correct. I agree to comply with all County
ordinances and,29e laws relating to building construction,
2e—
%��
this County to enterinspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE -
5/22/89
Si me of Appli...t.,/Wen' Date