HomeMy Public PortalAbout8915 HERMOSA DR_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION
PPLIC A TION COR PERMIT
I hereby affirm that I have a certificate of consent to self F1r r f9 1x/ r 1� PERMIT
insure, or a (7ertific8fceof Workers' Compepsation Insurance, HEATING - VENTILATING • AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C
Policy No. PC991��5, ,,4epublic Indemnity n6oPw97Be
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
xJ Certified copy is filed with Ioun au t g inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS 8915 Hermosa
DoteMar l "l r 9fl Applicant LOCALITtem le Cit
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE 1,
CERTIFICATE OF EXEMPTI FROM WO NEAREST
COMPENSATIO NSURANCE CROSSST. Rosemead .
ABSORPTION UNIT, BTU
(This section need not be completed if the rk involved by DISTRICT No PROCE eY
the permit is,for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM T VO
permit is issued, I shall not employ any person in any manner. BOILER, BTU
so as to became subject to the Workers'Compensation Laws. APPROVALS DATESPECTRSIGNATURE
Date Applicant COMPRESSOR, BTU PAIP b4il 12 00 ROUGH i /
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' LfA
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VAL DATI
with comply with such provisions or this permit shall be deem-
edrevoked. FURNACE: FAUW GRAVITY 12 0
LICENSED CONTRACTORS DECLARATION FLOOR BTU
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.
r
License Number C-20 Lic. (2alsl 751 , a'
• an add air conditioning 0 '
Contractor Date 3/13/90 14inlets & outlets 28 00 W
❑
0
1 am exempt under Sec.
Plan check fee tJ
W
8.8P.C. for this reason N
PERMIT ISSUING FEE $
Dote: 3 0 z
Signature TOTAL FEE 65 00
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME - ..
Professions Code):
'•
I, as owner of the property, or my employees with ADDRESS _ .... '
wages as their sole compensation,will do the work and ACCT _+T
the structure is not intended or offered for sale(Section CITY- - TEL. NO. •
7044, Business and Professions Code). OWNE 7,307 f•;LI Ill
❑ I, as owner of the property, am exclusively contracting �'ranklln Yang
-- - 1-ITEMS
with licensed contractors to construct the project (Sec- MAIL 8915 Hermosa
tion 7044, Business and Professions Code). ADDRESS- TOTAL 65 - 00
CONSTRUCTION LENDING AGENCY CITY Temple City IN. N0.285-9309
1 hereby affirm that there is a construction lending agency for - CHECK 65.OG
the performance of the work for which this permit is issued CONTRACTOR Bryant Htg & Air Cond. , ---• 'C_HANGE` ,130
(Sec. 3097, Civ. C.).
Lender's Name
ADDRESS 1350 E . Las Tunas Drive -
- O IOEI-011111 3�P19"I
CITY San Gabriel TEL. No. 286-1141
Lender's Address 9579
certify that LICENSE NO. CLASS
have read this application and state that the STATE LIC. C— - 7Jr y 1 HMif'=v4
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
hereby autho 'rrJrepresentotives of this County to enter
Po t v tioned property for inspe ion pur oses. - -
3 SEE REVERSE FOR EXPLANATORY LANGUAGE
ature of ApplI mnt y r,t Date
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