HomeMy Public PortalAbout9920 DUFFY ST_Mechanical__ DEC
WORKERS' COMPENSATION cafe of cons APP CIAMON FOR PERNT
I hereby affirm that I have a certificate of consent to self LL jJ�f U' �( V� .
insure, or a certificate of Workers'Compensation Insurance, " VENTILATING
nA
or.o certified copy thereof (Sec. 3800;.Lab. C. 20A346 DPW 9/88 ������� - V 6N 11�6Pu U BN� " AIR ®�®V4B®�011�� .
Policy No. 994,357 Company Republic indemnlry .
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy-is filed' h'1 county,b Tiding inspec- [NEAREST
G
tion epart ent. FOR APPLICANT TO FILL IN ADDRESS
. 9920' Duffy Street' .
on (PRINT OR TYPE ONLY)
Date' Applican{ Y Temple City
/ NO. -TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEM ON FROM WOK RS'
COMPENSATION INSURANCE ST. Baldwin
ABSORPTION UNIT, BTU '
(This section need not be completed if the work InVOIVed by DISTRICT NO. PROCESSED BY
the permit is for.one hundred dollars ($100) ordess.)
1,certify that in the performance of th'e,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 INSPECTOR'S SIGNATURE
Date Applicant l COMPRESSOR, BTU L ,o ROUGH „? �I
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 (y�,LIDATIOilIs
with comply with such provisions or-this permit shall be deem-
I' ed revoked. FURNACE: FAU _GR V TY JvJ�.
LICENSED CONTRACTORS DECLARATION 1 FLOOR BTU
-
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED-UNIT-
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business WALL.
and Professions Code,and my license is in full force and effect.
-inlets & lets }
License Number 221 7.51 Lic. Class'-2n a'
U
Contrcictor 4. Date - $/71 89
I am exempt under Sec.
Plan.check feeLU
v
B.&P C'for jhis reason. CQ" CL
Date: PERMIT ISSUING FEE $ �
Signature
TOTAL FEE _ !c _
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License y
Law for the,following reason (Section 7031.5, Business and' NAME
Professions Code):
. ADDRESS
❑ I; as owner of the property, or my employees with
wages as their sole compensation,will do the work and - - P4k.4Tov
the structure is not intended or offered for sale(Section CITY - TEL. NO. _
,x,07
7044,,Business and.Professions Code). - 42.15❑ OWNER
I, as owner of theproperty, am exclusive) contractin David Yocum
exclusively,contracting . . _ � ITEM
with licensed contractors to'construct the project (Sec- MAIL _.
tion 7044, Business and Professions Code). ADDRESS 9920 Duff. Street TTNA 2-.75
CONSTRUCTION LENDING AGENCY CITY Ple Cty TEL. No. "" ""
CHECK 42.75
285-890
I hereby affirm that there is a construction lending agency for
the,performance of the work for which this permit is issued
(Sec. 3097, Civ. C.). CONTRALTO r ant Ht & A/C inc _ ,..t:}( [ ._... ,Q(]
ADDRESS
Lende'r's Name 1350 E. •LaS Tunas Dr �y �y/
CITY TEL. NO. VV-01MIt• t7/3JJ80,
Lender's'AddressLIC. 2 -1:141
b 1 PM 40
I certify that I have read this application and state that the LICENSTATESE NO. 221751 CLASS
C-20
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
vpo t e 6 v mentioned property for inspection p'rposes. -
SEE REVERSE FOR EXPLANATORY LANGUAGE
Xign-cure of Applica r Agent Date s O
P