HomeMy Public PortalAbout5743 CAMELLIA AVE_Mechanical__ WORKERS`COMPENSATION D$CLARATION CEA 8818 (2-80) APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of convent to self
Insure,'or a certificate of Workers'Compensatlon Insurance,or HEATIN -V ENTIL.ATIN -AIR CONDITIONIPKG
■certified co tho o c. 38p0 Lab, �
Po1lcgNo3��79�O�tpany Ga. 6asualty, indemnity
D, Certlfted copy Is hereby furnished.
9T COUNTY OF S ANG ES BUILDING AND'SAFETY
Certified copy 14 flled.,Aith the county bul1ding inspection BrJILDING
dap �{ FOR APPLICANT TO FILL IN ADDRESS 4 N Camellia Avenue
Date9 Applicant E; L; PAYNE COMPANY (PRINT OR TYPE ONLY)
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APFILIANCE OR EQUIPMENT FEE LOCALITY '1 e City
COMPENSATION INSURANCE NEAREST
CROSS ST, Lower Azusa Road
(This &&ctloti need not be, completed if the Work involved ABSORPTION UNIT, BTU
lv
by the permit it-for one hundred dooms ($100) or tiers..) DISTRICT 40. P R OCESS�z D By
I certify that In the performance of the work for which this AIR HANDLING UNIT CFM Q y
permit Is issued, I shall not employ any person in any manner UU Q
so as to become subject to the Workers' Compensation Laws. BOILER BTU U
APPROVALS DATE INEP ECTOR'3 eIGNATURE
LU
Date Applicant COMPRESSOR BTU
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
r
Exemption, you should become bubjact to the Workers' VENTILATION SYSTEM FINAL
Compensation provisions of the Labor Code, you must forth-
with comply with such providdns or this permit shall he EVAPORATIVE COOLER VALIDATION
deemed revoked.
LICENSED CONTRACTORS DECLARATION 1 PLOORA: FAU BTU I •20 00
I hereby affirm that 1 qm flcenied under provisions of Chapter HEATER: SUSPENDED 1JNIT C
9 (commencing with Section 7000) of Diyision 3 of the Susi- SHALL
nese and Professions Code, and my license is In full force and
effect. ���������QQ��
License Nurnber.3.�S1.4.45h. _ Lie.Clara C-20
Contractor E. Li PAYNE Data , 9=26-80
I pm e"mpt from,the licensing requirements as I ■m a
licensed architect or a registered professional engineer J Plan check fae�25%of above.
acfing In my profeaslonal capacity (Section 7051 Bur-
lneu and Professions Code). PERMIT ISSUING'FEE$
Lie.or Rey.No. Data TOTAL FEE 27 1 00 J
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 1
I hereby affirm that I am exempt from, the Contractq�'s NAME 2 ��
License Law for the following reason (Section 7031.5, Bum
nessand Professions Code): ADDRE
❑ I, as owner of the property, will do the work and the —"�—'
CITY TEL. N
structure Is not intended or offered for sale (Section om.
7044, Bu Mn era and Pro fesalons Code). �2'4 2 2 A
1, as owner of the prdperty, am exclu&lvely contracting OWNER Mr Charles Burns - • • •'•
with licensed contractors to construct the project MAIL # I 4
(Section 7044,Business and Professions Code). ADDR 5743--"N', Camel 1 i e Avenue
CONSTRUCTION LENDING AGENCY CITY TempTe City TEL.NO. ' 28]-494'3 '•'• •
I hereby affirm that there,is a construction lending agencyy 10'O
for the R
performance of the work for which this permit ►s CQNTACTOR E. t. PAYNE-CORPANY
issued ' 309'7,Civ.C.).
Lender s Name ADDRESS 166 W Live Oak Avenue
Lender's MiIress LSTATE
TEL NO. 446-6118
I certify that I have read this application and state that the LIC. 'C-.,20
above Information Is correct. I agree to comply with all CountyNO. 120228 CLASS
ordinances and State laws regulating Hesttng, Ventilating end
Air CQnditkning, and hereby thori—representatives of this SEE REVERSE FOR EXPLANATORY LANGU,�,GI:
County enter upon th bovo entinned property for
lull urposes. '
ngtat oflPetmitt Data �j