HomeMy Public PortalAbout8615 HERMOSA DR_Mechanical__ YJUPinEth COMPENSATION DECLARATION APPLICATION FOR PERMIT
Thereby affrcm that I rhave a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.)
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Policy No.X{yt_SLL�ComOpOany LtTaGt Am Tns- CO
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy Is hereby furnished.
® Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS 8615 E. HermsIa Dr.
LOCALITY
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION F M WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. v
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT Ivo. PRoces rD av /
the permit is for one hundred dollars(§100)or less.) AIR HANDLING UNIT,CFM �i�
I certify that in the performance of the work for which this I
permit is issued, I shall not employ anyperson in any manner
so as to become subject to the Workers Compensation Laws. BOILER, BTU APPROVALS DATE INS�CTOR's SIGNATIJa
AppliCOMPRESSOR, BTU D de) ROUGH _ /r c
Date cant
- -
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VA L IDAT ON
with comply with such provisions or this permit shall be
deemed revoked. FURNACE_ TAU GRAVITY a �l
LICENSED CONTRACTORS DECLARATION FLOOR BTU U' U
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED—UNIT
with Section 7000) of Division 3 of the Business - WALL
and Professions Code, and my license is in full force and effect. d
License Number 46-9.166 Lic Class r-27 - ► � V
Contractor
er 1 Heat A/gb 7/7/86 0
❑ 1at�L
am exe pt underec. /` W"
Plan check fee d
B.&P.C. for this reasonN
PERMIT ISSUING FEE § Q
Date: - I TOTAL FEE 6-V ;24 9 7.8 A
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT '# e e s e e 8
I hereby affirm that I am exempt from the Contractor's License 'I.^ - 30.5 0
Law for the following reason (Section 7031.5, Business:and NAME G Q 4- A r 'e e - 30.5 O�
Professions Code): .
❑ I, as owner of the property, or my employees with ADDRESS .0 7.0 8'8 6
wages as their sale compensation,will do the work and
TEL NO.
the structure is not intended or offered for sale(Section CITY
7044, Business and Professions Code). -
El1, as owner of the property, am exclusively contracting OWNER Leonard Olson
with licensed contractors to construct the project (Sec- MAIL _
tion 7044, Business and Professions Code). ADDRESS
8619 F.CONSTRUCTION LENDING AGENCY CITYTEL. NO. 286-5441
I hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is issued CONTRACTOR General Heat & P.ir COnd.
(Sec 3097, Civ. C.). -
ADDRESS 1110 q 'd ..
Lender's Name
Lender's Address CITY Monrovia Ca -TEL NO.358-0022
STATELIC.
I certify that I have read this application and state that the LICENSE NO. 46 CLASS G-2
above 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 bove-mentionedroperty f Inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�Z/RZKZ
Signa re of Applicant or Agent Date