HomeMy Public PortalAbout5635 HELEO AVE_Mechanical__ WORKER'S
have a certificate
DECLARATION 76A34C 9/e9 APPLICATION FOR PERMIT LANE GREEN
6A364C
I hereby affirm that 1 have a certificate of consent to self insure,
or a zertiticate of Worker's Compensation Insurance, or a certified HEATING- VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
Policy No.1 173485 Z7,,pany CNA COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
Certified copy is filed with the count buildinginspection FOR APPLICANT TO FILL IN BUILDING
departmen. y p (PRINT OR TYPE ONLY) ADDRE555635 Heleo Ave.
Date_ 7Applicant,Gl�ti""x�r NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY Temple City
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM Dlsmx:T NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. / 5- O b
COMPRESSOR,BTU 0 6
APPROVALS DATE INSPECTOR'S SWNAIDflE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, atter making this Certificate of ROUGH
Exemption, you should become subject to the Workers' Compensation EVAPORATIVE COOLER r
provisions of the Labor Code, you must forthwith.comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU_GRAVITV I
LICENSED CONTRACTORS DECLARATION FLOOR BTU V ATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT_
(commencing with Section 7000) of Division 3 Of the Business'and HEATER: WALL ,r�o
Professions Code,and my license is in full force and effect. 3 —
License Number 469166 Lic.Class Cefdkfeo
General Heating & A/C , >
a
Contractor Date 0
❑ I am exempt under Sec. - Plan check fee V
Cr
B.&P.C.for this reason PERMIT ISSUING FEE $ Ct
Date: TOTAL FEE 05 W
Signature d
PLAN CHECK APPLICANT -
Z
OWNER-BUILDER DECLARATION
Z
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions /7
Code): ADDRESS P ! M
❑ I, as owner of the property, or my employees with wages •J
as their sole compensation, will do the work and the CITY mG�apV/� TEL.NO. -7 _0O ACCT.T4
structure is not intended or offered for sale (Section 7044, J 33503 521.!17JBusiness and Professions Code). OWNER - ITEMS 122&
❑ I, as owner of the property, am exclusively contracting MAIL 1 1 TEM S
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). TOTAL 52 a 05
CONSTRUCTION LENDING AGENCY CITY 742 ,�G/ Oi TEL.NO. /_ t
iH''tGt-�. 52.CI
c
r
hereby affirm that there is a construction lending agency for
the performance of the work for which this permit Is issued CONTRACTOR
_
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name
CITY TEL.NO. 7/12119,4/12119,4
Lender's Address �/69i66 _•''s
1 certify that I have read this application and state that the above LICENSE NO. CLASS �tI'�+ 1 A17111%�iir
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
_groperty forrJJptp�pec//tiiofon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
61GNATU' OF APPLICANT OR AGENT DATE