HomeMy Public PortalAbout9160 GARIBALDI AVE_Mechanical__ WOR,CEits' COMPENSATION DECLARATION APPLICATION FOR P E RM I T
I hereby affln, that I have a certificate of consent to self
Insure, or a certificate of Workeri.Com pbnatrtIon Auuronce, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. G) 76A364C
�y pay 20-0046 DPN 9/86Pall Na 9 913 5 7 company Republic Ind.
❑ Certified copy Is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
® !aectlon
5rwtbe
th ccEthelnvoF"d
ec- FOR APPLICANT TO FILL IN BU2DING
ADDRESS 9160 Garibaldi
(PRINT OR TYPE ONLY)Date L"`TYTem le CitNO. TYPE OF APPLIANCE OR E(]UIPhhEM FEEON FRONEAREST
N INSURCRass ST. Hart
(thisple d If by ABSORPTION UNIT, BTU DtSM)CT Nb. 9Y
the perrnft Is for one hundred dollars (;100) or loss.) f
I certify that In the,performance of the work for which this AIR HANDLING UNIT, CFM / O 111It
permit Is Issued, I shall not employ any person In any manner VV
so as to become subrect to the Workers s. BTU �rmwALs are IMSPL{70R5 S+orvArur�
Compensation Law
Data Applicant- 1 COMPRESSOR, BTU XX 36,000 Rough
NOTICE TO APPLICANT: If, aftef making this Certlflcate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER V AMv
with comply with such provisions or this permit shall be deem-
ed revoked: FURNACE: FAU
UCENS=D CONTRACTORS DECLARATION1 RCX)!2 BTU 5�� 12102
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPEN DIED UNIT-
(cdmmencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license Is In full force and effect.
2 (1) air in let & (1) air outlet 4 00 }
CL
License Num 0933 Ic. C-2n ►
O
R=lace furnace and add U
C:ontractar Air Conditioning p
❑ I ammpt under
Plan check fee uu
• a
B.BP.C. for this reason PERMfT ISSUING FEE $ 131 W
Date:
Signature TOTAL FEE 1 41100
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractors License ,
Law for the following reason (Section 7031.5, Business and NAME
Professions code): u
El1, as owner of the property, or my employees with ADDRESS ACCT,r
wages as their sole compensation,will do the work and
the structure Is not Intended or offered for sale(Section CITY TEL NO. ��-" 7 41.01c1
7044, Business and Professions Code}. OwNER 1 ITEMS
❑ 1, as owner of the property, am exclusively contracting
with licensed contractor to construct the project (Sec- ADDRESS 9160 Garibaldi TOTAL moi- 1 00
tion 7044, Business and Profession Code).
CONSTRUCTION LENDING AGENCY CITY Temple City Ta- NO- 285-3739 DEC' 41'00
1 hereby affirm that there Is a construction lending agency for , WWI 00
the performance of the work for which this permit is Issued CONTRACTOR
(Sec. 3097, ay. c) ADDRFss 1350 E. Las Tunas Drive
Lenders Name 0OXH)OO1 4f 4/%
Lend,Address CITY San Gabriel TEL N4-286-1141 ?%1 1 AM10:5ti
I certify that I have read this application and state that the u ACEnm No. 221751 UC7ASS C-20
abovoJaformatlon Is correc---tI agree to comply with all County
a ran and Stat elating to building construction,
d here e r esentatives of this County to enter
Pon th n property for In
� SEE REVERSE FOR EXPLANATORY LANGUAGE
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