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HomeMy Public PortalAbout9462 DAINES DR_Mechanical__ 76A364C WOF;KERS'COMPENSATION DECLARATION CE-818 (2-80) Q P Ifs Lb..UC AT Q O 1 rl FOR R PE R� T I•hereby affirm that I have a' certificate of consent to self insure,or a certificate of(Workers'Compensation Insurance,or HEATING-!VENTILATING-AlR CONDITIONING a certified copy thereof(Sec, 3800,Lab.C.) ' Policy Noyje5.9.9:9- npany-We-s�t—Am'e'TiC-ari^ COUNTY OF LOS ANGE ES iN.G ARID SAFETY Certified copy is hereby furnished.. �' Certified copy is filed with the county building inspection FOR APPLICANT TO Fl LL IN UI'LDING department>, ADDRESS Date_10-2.9=O.E)aplicant.unlveY'sa-1—Plb•g (PRINT,OR TYPE ONLY) 9' Z-2—Dalme-s— CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE Of APPLIANCE OR EQUIPMENT FEE LOCALITY Temple City COMPENSATION.INSURANCE NEAREST (This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. a by the- permit is for one hundred dollars ($100) or less.) DISTRICT NO. P ESSE er O f certify that in the performance of the work for which this AIR HANDLING UNIT,CFM �/9d d� permit is issued, I shall not employ'any person in any manner so as,•to become subject to the.Workers'Compensation Laws. . BOILER,BTU O APPROVALS DATE INSPECTOR'S SI ATURE V Date___ `���A ''''ican' COMPRESSOR, BTU W 10XrXzs/t )a0 Uri l '1 - ROUGH NOTICEXX:kXVENTILATION SYSTEM ?LICANT: If,.after making this CertiM:ate of N Exemption, you should become subject. to the- Workers' FINAL Z_ Compensation 'provisions of the Labor Code, you must forth- EVAPORATIVE COOLER- with comply with such provisions or this permit shall be VALIDATION deerried revoked. .'FURNACE:-, FAU GRAVITY LICENSED CONTRACTORS DECLARATION . FLOOR': BTU 'I hereby affirm that I am licensed under provisions.of Chapter HEATER- 'cPENDED UNIT // 9 (commencing with Section. 7000) of Division 3 of the Busi- WAL /40 ®o ness and Professions Code,and my license is in full force and effect. License Number38_( 7T Lic.Class C20 SC36 con,Unversal_Elb_ Date_1.0-2.9_80 ElI am exempt from the licensing requirements as I am a i licensed architect or a registered professional.engineer' Plan Check fee 25%of above. acting in my professional capacity (Section 7051, Bus- iness and Professions Code). PERMIT ISSUING FEE $ Lic.or Reg.No. Date TOTAL FEE HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from-the Contractor's NAME, License Law,for the following reason (Section.1031.5, Busi- ness and ProfessionsCode): ADDRESS I, as owner of the property, will do the work and;.the0 2 8 61'5 R structure is not intended or offered for sale (Section CITY TEL. NO.' 4 7044, Business and Professions Code). o Io 0 0 (J 1 aOWNER 1, as owner of the property, am exclusively contracting Bred eal' with licensed contractors to construct the project MAIL (Section 7044, Business and Professions Code). ADDRESS -94.62 2,© 0 1 ,7 O 0 Daines DT TEL.NO. 1..7 0 0 5 CONSTRUCTION LENDING AGENCY CITY Temp.l.e C.i_t_y I hereby affirm that there is a'construction lending agency Q 30—, 80 for the performance of the work for which this permit is CONTRACTOR issued(Sec. 3097,civ.C.). Univers-a-1 plb'g Lender's Name ADDRESS__ 2631 Lee Ave Lender's Address CITY TEL. NO. S_o_EL_Mon.te 5.7_5-3460 - 1 certify that I have read this application and state that the STATE LIC. above information is correct.I agree to comply with all County. LICENSE NO, 386678 CLASS 4788 S 8 ordinances and State laws regulating Heating,Ventilating and Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE County to enter upon the above-mentioned property for , p:ction pu il Z!�___17 7_ 0 ignature ofPreprom.itst.ee Date t T§A364--CEB,B-1./70 APPLICATION FOR PERMIT � HEATING - !VENTILATING - AIR CONDITIONING . COUNTY OF LOS ANGELES BUILDING DEPARTMENT OF COUNTY ENGINEER ADDRESS _S Dc. BUILDING AND SAFETY DIVISION LOCALITY JOHN A. LAMBIE. COUNTY ENGINEER COLEMAN W. JENKINS, SUPERINTENDENT OF BUILDING NEAREST CROSS ST. c>v FOR APPLICANT TO FILL IN OWNER `F (PRINT OR TYPE ONLY) ( r� -Z MAI L NO. TYPEOFAPPLIANCE-OR EQUIPMENT FEE ADDRESS '�4 2 CITY [C,,,1n !�e TEL. NO./LaS_-2 Sh;Z ABSORPTION SYSTEM, BTU Se CONTRACTOR AIR HANDLING UNIT, CFM ADDRESS BOILER, HORSEPOWER CITY TEL. NO. COMPRESSOR,, HORSEPOWER STATE LIC. LICENSE NO_ CLASS VENTILATION SYSTEM DISTRICT NO. CLASS GROUP ZONE PROCESSED BY EVAPORATIVE COOLER FURNACE: FAU_GRAVITY FLOOR BTU INSPECTION'RECORD HEATER: SUSPENDED UNIT_ WALL CAS O V O 1-- • U NEW >CADDITI'ON_ PERMIT $ 3 00 CL N Z_ ALTER-REPAIR- TOTAL 'FEE $ `J - PLAN CHECK APPLLCANT l NAME ADDRESS CITY TEL.NO. I HEREBY ACKNOWLEDGE THAT IHAVE READ THIS APPLICATION AND STATE THAT THE ABOVE"IS CORRECT AND AGREE TO COMPLY WITH ALL ORDINANCES AND LAWS REGULATING HEAT IING, VENTI- - APPROVALS DAT - SPECTO 'S SIGNATURE LATING,.AIR CONDITIONING. ROUGH _ I HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION OF CHAPTER9, DIVISION 3,. OF THE BUSINESS AND PROFESSIONAL FINAL CODE OF. THE STATE OF CALIFORNIA. SIGNATURE x �p�- JACK R. ALLEN,SUPERVISI ECHANICAL ENG'R, OF PERMITTEE GliGli6 PERMIT VALIDATION CK. M.0. CASH PLAN CHECK VALIDATION [fi 7'3 3_22_ OCT 26 41 D 7.00 SEE BACK OF APPLICATION FOR COM PLETE FEE SCHEDULE