HomeMy Public PortalAbout4940 DOREEN AVE_Mechanical__ (R, YORK-G'fi, that
CI have SATION DECLARATION APPLICATION
PPL ICA TION FOR PERMIT
I;;r�erebjr dffirm that I have a certificate of consent to self P9 IL Y1 G Ytl PERMIT '
or
CSI ora certificate of Workers' Compensation Insurance, 76A36aC - HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec 3900, Lab. C. CE'-818(REV. 10/8I) -
• Pcy No. SRI Company Sta T'ITnd
F1 - - - -
Certifiedcopyis hereby furnished. -COUNTY OF'LOS ANGELES BUILDING AND.SAFETY
-❑X' Certified copy is filed with the Icounty.building inspec- FOR APPLICANT TO FILL IN- - - BUILDING
tion department. (PRINT OR TYPE ONLY)' ADDRESS 49A0 N. Doreen
Date .. h 1—91_ApplicorlLOCALITY Temple City
NO. TYPE OF APPLIANCE OR EQUIPMENT 'FEE
.CERTIFICATE OF EXEMPTION FROMWORKERS' NEAREST
COMPENSATION INSURANCE 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 thatr
`-in the performance of the work'for which this - Q
permit is issued, I shall not employ any person AIR HANDLING UNIT,CFM
n in any manner
so as tobecome subject to the Workers Compensation Laws. BOILER, BTU y APPROVALS DATE INSPECTORS SIGNATURE
Dote Applicant COMPRESSOR,BTU J 6000 _ ROUGH -
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM. FINAL -
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you-must forth- EVAPORATIVE COOLER VALIDATION
with comply with such'provisions or, this permit shall be -deemed revoked. FURNACE:. � FAU GRAVITY
LICENSED CONTRACTORS DECLARATION / FLOOR BTU S_..f_600 "
hereby affirm that I am.licensed under provisions of Chapter 9SUSPENDED UNIT - ,
'(commencing with Section 7000).of Division 3 of the Business HEATER: WALL .
and Professions Code„and my'.license is in full force and effect. p ' -
�O �'O 0
License m er Lic. Class S-7fl D V-
K
Contra or ate (—l'1—A1 O
F-1I m
am'exept,u nde}Sec. .._„ W
Plan check fee - - o-
B.BP.C. for this reason1101
Date: PERMIT ISSUING FEE $ / - Z
S'anature .Z4 L _ TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT -
I.hereby affirm that I am exempt from the Contractor's license D - -
Low for the following reason (Section 703.1.5, Business.and NAME
Professions Code)'
❑ I, as owner of the property, or my employees with ADDRESS - E
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
El1: as owner of the property, am exclusively contracting !TEM-'
with licensed contractors to construct the project (Sec- MAIL - - - it �__
- 1.-TAL - s- r m 1
' tion 9044, Business and Professions Code). ADDRESS —
CONSTRUCTION LENDING AGENCY CITY TEL. NO:
'I.hereby affirm that there is a construction lending agency for (t _II=the performance of the work for which this permit is issuedONTRACTOR'. ,It1
(Sec. 3097, Civ. C.).
Lender's Name ADDRESS 7 _
CITY .s ... TEL. NO. )f,ilJl IT'U1=A wjy:"1
Lender's Address - -7-1
STATE LIC. 7: 1 y;-j
I certify that I have read this application and state that the LICENSE NO. i D CLA55 - - - - - -
above information is correct. I agree to comply with all County
ordinances and Stale lows relating to building construction,
and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date •- - - - ' - -