HomeMy Public PortalAbout9849 ESTRELLA AVE_Mechanical__ WOE ,R'S COMPENSATION DECLARATION - 7SA364 DPW 9/89 ,gppLIC�,TION ;FOR PERMIT yny[(,t1 GREEN]6A364C ��M E G I� E E 1'ryl;
I hereby affirm Q;t I have a certificate of consent to self insure, / YY tl �V111�1 'Ll ll CI
or a cOp+Mcafe of Worker's Compensation Insurance, or a certified HEATING-VENTILATING -AIR CONDITIONING`
copy thereof(Sec.3800 Lab. C.) `• -�'-
Policy No. W9 S 1 1 1 3(k(dApany Ca 1 Cn1Rp - COUNTY OF LOS ANGELES DEPT-OF PUBLIC WORKS BUILDING AND SAFETY DIV:
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Certified copy is hereby furnished.
Certified cots filed with the t i i specfion FOR APPLICANT TO FILL IN - BUILDING
copy ADDRESS 9849 Estrella
department. (PRINT OR TYPE ONLY)
Date` 419/95 Applican/ f _ NO. TYPE OF'APPLIANCE OR EQUIPMENT .FEE NEARELOCALIST.TelllPl2 C1t17
CERTIFICATE OF'EXEM1,PTION FROM W ERS' - CROSS ST:
COMPENSkION'INSURANC .ABSORPTION UNIT,.RTU -
This section need not be completed,if the work involved b the ASSESSOR
( Y MAP BOOK � PAGE_'�,� PARCEL-•`�.•
permit Is;for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM -
certify that in the performance oP the work for'which this permit oISTRIcr No. PRocssss0 av
is issued{ I shall not employ any person in any manner so.as to .BOILER,BTU-
become subject to the Workers' Compensation Laws
nn COMPRESSOR,BTU �� •
APPROVAL$ _ DATE INSPECTOR'a SIGNATURE
Date Applicant VENTILATION SYSTEM'
_
NOTICE-TO APPLICANT: If, after making this Certitic ateof ROUGH
Exemption,you should become subject to the Workers"CompensationEVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL Z-, ,� Jr
provisions or this permit shall be deemed revoked. FURNACE: FAU_GRAVITY -
LICENSEDCONTRACTORS DECLARATION Ise—en .lDlets
FLOOR 'BTU T 041,0 VALIDATION
hereby affirm that I am licensed urider provisions Of Chapter 9HEATERSUSPENDED—UNIT—
commencing
USPENDED UNIT_
(commencing with Section 7000) of Division 3 of the Busiriess and : WALL ..
Professions Code, and my license is in full force and effect.. - 2 �� �4 / ,"'r'✓"� .
& outlets
Licens um 221 51 Lia Class
Contract - Date +F1, ��)
' Plamcheck fee - '- l;
am exempt under <
- B.&P.Ci for this reason - PERMIT ISSUING FEE $ G + jrF O
�5..
Date: 'I'Tr� sCh 's3-C.?,C)
TOTAL FEE D Htt f. �IR ',4i1 W
Signature d
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT f'UHr.E.UF III1. 00
Z,
I hereby affirm that I am exempt from the Contractor's License Law NAME D -
for the following reason (Section 7031.5,:Business and Professions ..
i
Code): ADDRESS ',I±1d I[I—[li{[f y-1
I, as owner of the property, or my employees with wages
as their sole compensation, will do the'work and the CITY TEL.NO. hI)�_� Yi1111
structure is not intended or offered for sale (Section 7044, - t
Business and Professions Code). OWNER Harold Bell
I, as owner of the property, am exclusively contracting MAIL . .
with licensed contractors to construct the project (Sec- ADDRESS 9849 Estrella
tion 7044, Business and Professions Code). CITvT eID - TEL.NO.
CONSTRUCTION LENDING AGENCY ple - - ,
'286-0623
hereby affirm that there is a construction lending agency IOrd '13
CONTRACTO D
t he performance.of the work for which this permit Is issue '. ryant htg. & ASC Inc. -
(Sec.3097,Civ.C.).
ADDRESS 1350 E. Las Tunas drive
Lender's Name'
CITY San Gabriel TEL.NO. 286-1141
Lender's Address STATE LIC. _
I certify that I have read this application and state that the above LICENSE NO. 221751 CLASS C-20
information is correct. I agree to comply with all County ordinances
and State laws relating to udding construction,and hereby authorize -
r r ntativee I t Cc my to enter upon the ab 7e- ntioned -
pertr Urposes, `— .SEE REVERSE FOR EXPLANATORY LANGUAGE
G URE OF APPLICANT OR PG - HATE
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