HomeMy Public PortalAbout5469 ENCINITA AVE_Mechanical__ _76A 364C 1` p p (�/�
WORERS CnMPENSATION rDECLARATION CE 918 (2-80)'> ,. A P P 1� C A T I O Yl FOR PER U�U T
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I hereby/a In that I have a certificate of consent to self e'
insure,s s cUeitrficate of Workers'Compensation Insurance,or I •' HEATING-VENTILATING-Alla CONDITIONING
a certified copy thereof(Sec 3800,Lab C) - I r I
P28849 Zenitrl I " 2 "fl
Potwy,No tiComparly t COUNTY OF LOS ANGELES BUILDING AND'SAFETY`
O1 Certified copy is hereby furnished _ '
f'rdCe4tir`�eI a py is filed•wit t ro building inspection << FOR APPLICANT TO,FILL ISN BUILDING
'Date_L � Applicar._�_ ° (PRINT OR TYPE ONLY)-` ADDRESS 54(i9 Encinl_ta
CERTIFICATE OF E EMPTION F M WORKERS' °NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY' Temple—C -ty
t COMPENSATION INSURANCE x NEAREST .
(This section'need-not be`,compieted if'the work involved ABSORPTION,UNIT;'BTU} CROSS ST` Q ,' O
by the permit is for,one hundred dollars ($100) or less) DISTRICT NO PROCESS BY U
I certify that in the performance of,the work for which this j AIR HANDLING UNIT,CFM- cr
permit is issued;I shall not employ any person,inanymanner O
§o as'eo become subject to the Workers' Compensation Laws BOILER;BTU 1-
"c APPROVAVS DATE INSPECTOR S SIGNATURE- U
Date Applicant
COMPRESSOR, BTU2=ton 1O QO ROUGH ��®� - y
NOTICE TO'APPLICANT If, after.making this Certificate of, ' VENTILATION SYSTEM + ' Z
Exemption, you should become.-subject to the 'Workers' FINAL
Comperisatton provisions of the Labor Code, you must forth,r �' VALI TION
EVAPORATIVE COOLER
Al
with comply_with;'such provisions,or this permit shalt be,
deemed revokedFURNACE FAU_%_ G-'Q6 1TY
LICENSED CONTRACTORS DECLARATION _` 1 FLOOR - BTU._15M- 10 00.-
I hereby affirrii that I am'licensed'under provisions of Chapter HEATER SUSPENDED UNIT
9 (commencing with',Section 7000)of Division 3 sof the Bust- WALL`
ness and Professions Code, and my license is m`full force and e
effect
License,Nu her_ 21]_51 Cl
Lie ass_C2_0 a_
Contracto _ Date ' s a }
I exempt r,om`the hcensmgyiegmrements as I am a'
licensed architect or a registered professional engineer Plan check.fee 250 of above
acting in, my"professional capacity (Section 7051,=Bus-
iness and Professions Code) PERMIT ISSUING FEE $ 10� 50
Lic For Reg No "' _ Date . �' TOTAL FEE ` 30 50 a o ra 5,3 3 9.A
• "HOMEOWNER-BUILDER DECLARATION` `PLAN CHECK APPLICANT` _ � 'G� a _ #fo o'o opo1
8
' 2�° 3`0;'5'0
I hereby affirm,. that,I am exempt from*the Contractor's " NAME + oroio 5 U
License Law for the following•reason (Section 7031 5, Busi-
ness arid-Professions Code) " ADDRESS • _ 0 R 1•9'—,,
8
• �� I, as owner of the-property; will d-o ,the work and the, f CITY t TEL NO
`"structure,is not `intended or offered for sale (Section i -
7044, Business and Professions Code),
O "I,'as owner of the property, am exclusively contracting' • OWNER Wesley PACK k
with licensed contractors to construct the project MAIL 5469 Encinita
(Section 7044, Business and Professions Code) ADDRESS
CONSTRUCTION LENDING AGENCY _ CITY Temple City TEL NO 286 826 "
I Hereby affirm that there is a construction lending agency
for the performance of the work-for which this permit is CO-,NTRACTOTryant Heat . &_ Alr COnd_. g
issued(See 3097,Civ C) _
`Lenders Name ADDRESS
' 3 59 E_.—L°a s—T_una_s=:D-r-lire
Lender's Address `
CiTYSanGabriel TEL No "286=1141
I certify that I have read this application and state that the' ELTIEN=sEo
LIC
above information is correct I agree to comply with all County 221151 CLASS C2Qy q,
ordinances and State laws regulating.Heating,.Ventilating and a
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE-
C int6to nter upon the above-mentioned roperty foru siposes
gn ture of P r nittee Date