HomeMy Public PortalAbout5949 ENCINITA AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C• APPLICATION
I�I�1 py p� p PERMIT 1 h@reby affirm that I have a' certificate of consent to. self � CL• .818 (2.80) A Ir Ir L.IC A I I O 1 tl FQ R r C R M I 1
'i&sure,'ora•eer1ficate of Workers'Compensation Insurance,or - HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec.'38bO, Lab. C.) '
Policy No. Company
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspection
department. FOR APPLICANT TO FILL IN BUILDING
Date Applicant (PRINT OR TYPE ONLY) ADDRESS 5949 Eneinita_Ave,
CERTIFICATE OF EXEMPTION FROM WORKERS'
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY Temple City, Cal.
COMPENSATION INSURANCE NEAREST I y
(This section need not be completed if the work involved ABSORPTION UNIT, BTU— CROSS ST. Las Tunas 0
by the permit is for one hundred do 'SI00) or les ) DISTRICTNO. PROCESS F BY
1 certify that in the performance t rk is s AIR HANDLING UNIT,CFM
permit is issued, I shall not empl • a ersr n a .y ler O
so as to become subject to the er C, I,.n . ' BOILER, BTU f U
APPROVALS DATETORE W
Date-6/_683 Applicant ` _ _ COMPRESSOR,BTU-60-1_0.0.0_= ROUGH
NOTICE TO APPLICANT' -4 uf,ar making this Certificate of VENTILATION SYSTEM L Z
Exemption, you should become subject to the Workers' FINAL
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER /—!
with comply with such provisions or this permit shall be VALIDATION
deemed revoked. FURNACE: FAU—X_ GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU 12_Q�OQO—
I hereby affirm that i am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section'7000)of Division 3 of the Busi- WALL a if
ness and Professions Code, and my license is in full force and NSPECTOH'S IGNA'
effect.
License Nurrb05_1676_ Lic. ClasS C-20
ContractoR. Walter Date 6/6/83 -
❑ I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan Check fee 25%of above.
acting in my professional capacity (Section 7051, Bus- y-s
iness and Professions Code). PERMIT ISSUING FEE $ '&? —j-t,
Lie.or Reg.No. - Date TOTAL FEE f7
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT -
-2254'7A
1 hereby affirm that I am exempt from- the Contractor's NAMErt '
License Law for the following reason (Section 7037.5. Bust.
James W:—M2__ln II o •;a s s 8
ness and Professions Code): ADDRESS5949 En_cin
ta_Ave, I -.-.405
• 4 0'60
❑ 1, as owner of the property, will do the work and the
structure is not intended'or Offered for sale (Section CITY t TEL. N0..28S=3HS3 I Is
Temp.le_Ci- y • • • 4060
7044, Business and Professions Code). Martin II.W
❑ . .t
I, as owner of the property, am exclusively contracting OWNER James QIb 0,6—8,3
with licensed contractors to construct the project AMAIL
DDRESS 5949 Eneinita Ave.
(Section 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.TEL.No. 285-3853
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR
issued (Sec. 3097,Civ.C.). RO}�.ert Wd1t Cr
Lender's Name ADDRESS 5608 Alessandro Ave. '
Lender's Address CITY TEL. NO. -
Temple City 287-0810
1 certify that 1 have read this application and state that the STATE LIC.
above information is correct. 1 agree to comply with all County LICENSE NO. 351676 CLASS C-20
maw
te laws re dati gating, Ventilating andan I arab a ., re representativ.. of ¢ SEE REVERSE FOR EXPLANATORY LANGUAGE
n e-menti�d p ,pe for�t e Date