HomeMy Public PortalAbout9662 GARIBALDI AVE_Mechanical__ i'-WORKERS' COMPENSATION DECLARATION
I areby affirm that I have a certificate of consent to self APPLICATION FOR PERMIT
Insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
ora certified copy thereof (Sec 3800, Lab. C.)
Policy No. PC99135�- Republicmpany- Indemi ty X0046 DPW 9/88
❑ Certified copy Is hereby fu COUNTY OF LOS ANGELES BUILDING AND SAFETY
® Certified copy Is filed wl th un g Inspec- FOR APPLICANT TO FILL IN
tlondepartment. AmRss 9662 E. Garibaldi
(PRINT OR TYPE ONLY)
Date 1/4/91 Appllc t a LOCALrrY
NO. TYPE OF APPUAfJCE OR EQUIPMENT FEE
CERTIFICATE OF FROM WO NEAREST
CROSS ST.
COAAPEIJSA I NSd RANCE ABSORPTION UNIT, BTU
(This section need not be coh+pleted If th*work Involved by DMTRfcr NO. BY
the permit Is for owe hundred ars (;100) or len.) r B
I certify that In the perform o t r which this A1R FWTDUtJG UNIT, CFM
lyermlt Is Irpued, 1 shall not p y any manner
so as to 9ec m ub act to a nzatl n La BOILER BTU APPROY S DATE ��p�{7p{�SgN�T�
Date ! II 1 COMPRESSOR, BTU ROUGH
NOTICE TO APPLICANT: If ma Ing thl C iflcate of vEMILATFON SYSTEM FINAL
�xemptlon, you should ome subjecttj t Workers'
Compensation provisions f the Labor Code, must forth- EVAP04 ATM COOLER 00 VALIDATION
with compI with such provisions or this permit shall be deem-
ed revoked. FURNACE: FAUX _GRAvrrY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that'l am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT-
(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license Is In full force and effed. V
r. }
License;. P.
m Ic. CI r-20 , a
O
Contre
/4/91
❑ xempt under rj
Plan check fee / � W
C for this feoso d
PERMIT ISSUING FEE;ff12�� Z
Date:
TOTAL FEE
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLOC'ANT
I hereby affirm that I am exempt from the.Contractors License
Law for the following reason (Section 7031.5, Business and NAME
Professions Code): O
❑ 1, as owner of the property, or my employees with ADDRESS i
wages as their sole compensation,will do the work and ACCT.T
the structure Is not Intended or offered for sale (Section CRY TEL NO. 106.00
7044, Business and Professions Code). CMRNER
❑ I, as owner of the property, am excluslvely•contracting Diane Harper 1 1TMJ
with licensed contractors to construct the project (Sec- MAILADDRESS 8662 E. Garibaldi. TOTAL 106 - 00
tion 7044, Business and Professions Code.
CONSMCTION LflJDING AGEN CITY 91780 TEL "°285-2837 ' 1CIb.NI
l
I hereby affirm that there Is a construction lending agency for
the performance of the work.for which this permit Is Issued CONTRACTOR
(Sec. 3097, Ov. C.) A/C
Lenders Name ADDS1350 E. Las Tunas Dr. 0000-COD1 1/21/91
CITY TEL '-286-1141
Lenders Address San Rahriel 91776 1 AM 10:IJ6
I at I have read this application and state that the STATE SE NO CLASS UC -20
bove in rmat Is co . I agree to comply with all County ,
221751
crdlnanc relating to building co tructlon,
and h e ze esentatives of this Co ty to er
th v I pr for I
1 SEE REVERSE FOR EXPLANATORY LANGUAGE
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