HomeMy Public PortalAbout10046 GREEN ST_Mechanical__ qq {� pp ��w� p[� tom.
WORKERS'COMPENSATION DECLARATION CEA 81'8 C(2 80) i"f.P}� B�P 9 Q �p FORPFR IVU I Il `
I hereby affirm that I have a' c6rtlflcete of coment'to self
insurd, or agertiflcateofWorkers'Compensation-lnsur4nce,oi H ATIFV -VE�TIIrATI G-i41RI.CONDCTI�rVIFL�C
a certifled Campy thereof(Set. 3800,'LAb.C.) - LJ
Poflcy.No; * Company
Q Certlfled Copy is here6y furnfshed, CO":ry O-F LOS All! LES . $171 LD.ING AAlD SAFETY;
Certifled'cgpy is filed with the county building Inspection BUI LDING `—
dapartm_ent. FOR APPLICANT TO Fi LL IN: . '• A4DF E �7 '
Date Aipplicant, (PRINT OR TYPE ONLY)
NO,_ TYPE OF APPLIANCE OR ECIU]PMENT' FES LOCALITY y "•�y�
..CERTi1'IC.1'rE OF EXEMPTION FROM PORKERS' - • '
CbMPENS.ATION iNSURAIQCE, " NEAREgT
(This section need not be co�apIdted if the wwoqrk tavotyed - ASSORI'TtON UNIT, BTU OROS$$L..
by tfte permit It for 'one hundr¢d dollars ($100) or'leee.)' _t''' DflrrnloTro, t�� By '
1 coytlfy that-In the perfotmartca of the work for'v4tich this AIR HANDLING UtJ T CFM
perrnit.Is'Lau6d,I%hell not'employ any person In any.manner �d `
an
as tab o e sub)ecjto the Workers' Compe tioo`n Laws. BOILER BY - O
`(IlateD �ApAilcatstIJ6"- AFFiOVALT [SAYE inarecTorrsaiQr+�Tti,Re
COM RESSORi •BT l
ROUGH G2'�Z�
NOTICE�t7 APPLfGANT: If, 4fter maklog this Certitloste of. VENTILATION SYSTEM �lNAt Z
Examtlon, you,should become.4ubJect tq the Workers'. ' -
'Compensation provisions of the Lab6f (ode,Wu must fdtth _
With comp)y with Auch ptovidons or-t)tis permit shall be J �fAPC1RATIVE,COOLEq' VA_L1QAT•1QN
deemed ro,;uk d. FURNACE: FAU GRpcViTY r
LICENStI�C_ONTIkAQTORS DECLARATION FLOOR;_,_,._BTU
I hereby,afflrtn that 14m Ilcenped u'ldet provigibna of Chayter FMATER: 8USPENDED'^ UNtT �I +f•
9 (commencing with Sgetion .7NO)of Dtvis►on•9:of the Busl- WALL
ness and.P ns:%"ode ❑ ray ncen jo.Is in.full:fofab and
eff6ct. C�
Llcbnlld,NLlc_Class
WWI. f-w �Date l- W /rte
I am exempt from the 1lceating m4uiiernahtr at 1-am a
licensed architect or. 4_realttered profgtlonal Engineer Piaiq Ch%*, fee 25% above• +'
actlrig jn my pr�feaaidital capacity (Sectio- '7031; Bus- ^r"
Iness and Profesalons Code)." PE�II♦Illrt ISSUI G.FEE$
Llc:or Ije�.Np. Date TOTALTEE
.HOMI OWNER-BUILDER DECLARATION, PLAtaCHEGK APPLiCANT��' t•�
I hereby.gfilrm that 1 ant exeutpt from-.-tire C.Ontractoes NAME'
License Law for the.follwAring ioason (Section 7031_5-,-8*- '
nets and Profet8ont Coda): ADQRE39 V !lJ 1 t
1, as,owner of fhi -property,.will do the work1shd tie +� t
%tructum Is not Intended ot'offerod for sale (SeetWd CITY /��� �►�J
7044,�Bualnesa and Profeetiom Code). _
I,.Fa-owner"of•the OWNER �� '��� _ L.
properCy, and excluaivolY contracting ± 2.6 4 2 A-
tvlth licensed contractors to;tohahruc4 'the 'pro}eet MAIL
(Section t 44, Business and Pr Code): •ADDRE=SS +-[ +�=/��. `, o+a e..o 4t1
CONSTRIkCTIbN {ENDING riO$NC CIT. /�L �1` TEL. r
�. 2 e •�� '7w0.Q.
I hereby, 'affirm -that there 14 a constructforn 19nding agency .
for the performanoe pf the work for which this permit It, . COT 7ACTO R t o `'¢*r r
issued SSec, 3.097,Civ.C.): / 1 17 Q Q CS
Lender s Nome ADDRE35-
tender's Addreai CFTY TEL,N <,
r
I certify -that I hgve rted this applioatlon,and Vote that the 8T TE LLC.
abovefMFormaticw is cprrect.I agree to tomply with W County E CC
ordlh{neft,and State fawn reguleth4 Ideating, Ventilating and
Air ltloning and eby authorize repreaentattves of•this- SEE REVERSE FOR EXPLANATORY LANGUAGE
un y enter p th'e above mentl ed property for/�'� Q
L pe on aurae (..�T U� - :. .. •- :. _
Si ure of Permittee Date - - -