HomeMy Public PortalAbout4946 HELEO AVE_Mechanical__ 4 i
WORKERS'COMPENSATION DECLARATION { a �t
I hereby offiirm that I have a certificate of consent to self APPLICATI® FOR PERMIT .
insure, or a certificate of Workers' Compensation Insurance, 76 364C HEATING - VENTILATING - AIR CONDITIONING
olirtg,certified�nw hereof (Sec. 3800, Lab. C.
�� OME INSURANCE CEA-818(REV. 10/81) CHANGE OUT
Policy No.W 42a1ZICom #39978
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑X Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS (I
Date Applicant
6-29-84 E. L. PAYNE CO ' (PRINT OR TYPE ONLY) LOCALITY
NO. :, TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. Broadway
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED Y
the permit is for one hundred dollars (;100)or less.) �' r/
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM Q
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. IBOILER, BTU APPROVALS DATE INSP TOR'S SIGN TORE
Date Applicant COMPRESSOR; BTU ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL L G�
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDAT ON
with comply with such provisions.or this permit shall be
deemed revoked. FURNACE: FAU AVI Y
LICENSED CONTRACTORS DECLARATION. 1 FLOOR BTU OL1 �0�— 10 OO
I hereby affirm that I 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 effect. >-
A.
License Number 120228 Lic. Class C-20 , U
IIS
Contractor E. L:.PAYNE Date 6-29-84
a
❑ I am exempt under Sec. 2
Plan check fee
B.&P.C. for this reason
Date:
PERMIT ISSUING FEE $ 10 ]50SignatureTOTAL FEE 20
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 2 7 7,6 A
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME ' , 4- o'o'o o o.8
Professions Code): ' I • '
❑ I, as owner of the property, or my employees with ADDRESS 2.o o'2 0,5 0
wages as their sole compensation,will do the work and CITY TEL. NO. F _
the structure is not intended or offered for sale(Section
7044, Business and Professions Code).
OWNER 0707-84
E]
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS 4946 North Hel eo Avenue
CONSTRUCTION LENDING AGENCY CITY TEL. NO. 286-5479
I hereby affirm that there is a construction lending agency for Temple City
the performance of the work for which this permit is issued CONTRACTOR E. L. PAYNE COMPANY ,•
(Sec. 3097, Civ. C.).
Lender's Name ADDRESS 9242 Beverly Blvd.
Lender's Address CITY Beverly Hills TEL. NO. 793-1131
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. 120228 CLASS C-2O
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction, a
and hereby authorize representatives of this County to enter
pon bove-men ned property for inspection purposes. SEE.REVERSE FOR EXPLANATORY LANGUAGE
6=29-84
g at11re of Applicant or Agent Date