HomeMy Public PortalAbout8848 GARIBALDI AVE_Mechanical__ WOR KL1:S CU.t._..•',.�I1UN DECLARATION CEA 818C(2-80) A P,P L ICAC'i O 1 V FOR PERMIT
Ih7reby tlff7rm ',I,3c I have a certificate of cbtsent tocself
Insure, or aartifi_ite o�Wurtcers'Compensation Insurance,-or HEATING-V ENT IL.ATING-AI R CONDITIONING
Is certified copy thrcreof(S-ec. 3800,Lab.C-)
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Policy No. L.CoBipan,,�en�,th Natl. Ina.
' ❑ Certifrod copy Is hereby furnished. COUNTY OF LOS ANGELES BUI LDI G AND SAFETY
® Cartlfied copy is filled wraith the county bvlldtng inspection FOR APPLICANT TO FILL IN BUILDING QJ�
Det dept_aY�j�`o AppLlcatN•A,•Po�.t�de�ter,Inc. (PRINT OR TYPE ONLY) •ADDRESS �`rT� Garibaldi
LOCALITY Temple Ci ty
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EOUIPMEN-T FEE
COMPENSATION INSURANCE NEAREST
(This section need not be completed If the work LuvoNed ABSORPTION UNIT, BTU CROSS ST.
e
by tate .perntit is for one hundred dbllara (3100) or'1es&) DISTRICT W... PROCEBa2D B
I certify that Ln the performance of the work for which this AIR HANDLING LYNIT,CFM ! 613
permit is Issued, I shall not employ, any person In any manner — 1 lr
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so, as t8 became subject to the Workars' Comperuatlon Laws. BOILER BTU
APPROVALS - DATE R'S 91G-NATI
Data Applicant 1 COMPRESSOR,BTU 36•000 10, 00 W
ROUGH C0.
NOTICE TO APPLICANT: If, after making this Certificate ofVEN DILATION SYSTEM FINAL Z
Ekempilon, you should become subjact to the Workers' _
Compensation provislons of the Labor Code,-yoµ must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions of this permit shall be
deemed revoked. FURNACE: FAU
LICFNSi~D CONTRAC'I"ORS DECLARATION FLOOR: BTiJ 10 00'
I hereby affirm that I airs Ilcenseq under provisl(ins of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Bus)- WALL
nogg and Professions Code, sad my license is In full force and
effect.
Llcense Number 22x862 c.Class C20
0•A.P oin��,lnc . 9/5/80Contractor Date
aI am txempt from the licensing requirements as i ■m a
Licensed architect or a registered professional engineer Plan Check fee 25%'qf above.
acting Ip my professional capacity (Seztion 7051, Bur
mesa and Professions Code). PERMIT.ISSUING FEE $ 7100
Llc.or Reg.Np. Dote I TOTAL FEE 127b0
✓ HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from- the Contractors NAME
Licetua Law for the following reason (Sectlon 7031.5, Bwl-
noaa and Professions Coe): ADDRESS
El 1, as owner .of the property, will do the work and the
,ptructure Is not Intended or offered for sale (Section CITY TEL. NO. _
7044,Busrnap and ProfeAlons CGde).
❑ OWNER Gar tan
Pael
I,'es owner of the property, am exolustvely contracting
with licensed coptrectors to construct the project MAIL
:(Stiction 7044, Business and Prbfessions Code). ADDRESS 8848:.Garlbaldl
CONSTRUCTION•LENDING AGENCY CITY Temple City TEL.NO.287_ 2 0.9.0 A
I hereby affirm that there is a construction lending agency P41
for the performance of the work for which this permlt is CONTRACTOfl O.A.Poinde%ter Inc. .i.
Lnued See. 3097.Civ.C.). P BOa3067 �
Lender s Name ADDRESS 0
Lender's Address CITY Pasad.e.nA 91103TEL. No.794_11.91 ,
I certify that I have read thls application and state that the STATE LIC.
above information is correct. I agree to comply with all County S N 220862 CLASS C
ordinances and State laws regulating Heating, Ventilating and
Air ton ditloning. and hereby'at- horixe presentatives-of this SEE REVERSE FOR EXPLANATORY LANGUAGE
t t el upon th ova ropart. for
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