HomeMy Public PortalAbout4541 CLOVERLY AVE_Mechanical__ � -��NORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
L. et affirm that I have a certificate of consent to self
insure, or a certifidote of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C
folicy No. Company
686987 State Fund CE-818(REV. 10/81ItITY OF TEMPLE. CITY
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the unty bu ding i spe FOR APPLICANT TO FILL IN BUILDING
ADDRESS 4541 Cleverly Dr.
tion department.
(PRINT OR TYPE ONLY)
3-20-87 y LOCALITY Temple Cit Ca.
Date Applicant p y�
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPT/ON FROMFE
ERS' NEAREST ower Azusa
COMPENSATION INSURAN CROSS ST.
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars($100)or less.)
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
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE I' P CTOR'S SIGNAT RE
Date Applicant COMPRESSOR, BTU ROUGH
NOTICE TO APPLICANT:. If, after making this Certificate of 1 VENTILATION SYSTEM 5 .00 FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I.hereby affirm that I am licensed under provisions of Chapter 9 l HEATER: SUSPEND '0UNIT
.(commencing with Section 7000) of Division 3 of the Business — 10.00
and Professions Code, and my license is in full force and effect.
License Number 240186 Lic. ClassC36 11111. u
Adee 3-20-87 0
Contractor Date
❑ 1 am exempt under Sec. UJ
V
Plan check fee CL
B.&P.C. for this reason' Z
PERMIT ISSUING FEE $
Signature Date:
TOTAL FEE 25.50
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ►
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and # d 6 a
CITY TEL. NO.
the structure is not intended or offered for sale(Section
7044, Business and Professions Code).
OWNER Manuel Godinez I o a 2 5 5 0
El1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL 1 28 $, E1 Molino a 0.9 2 5.5 050
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITYAlhambra, Ca. TEL. NO. 281-6153 •0 3,2 5 i 8 7
I hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is issued CONTRACTOR Adee Plg & Htg Inc. ,
(Sec. 3097, Civ. C.).
Lender's Name ADDRESS 5457 Crenshaw Blvd
Lender's Address CITY L.A. , C.a. 90043 TEL. No. 759-9101
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. 240186 CLASS C36
above information i ect. I agree to comply with all County
A
es and ate I s relating to building construction,
eby au orize epres atives of this County to enter
abo a-me Ione pr perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of licant or Agent Date