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Home My Public Portal About9527 KENNERLY ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 76AC APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self Insure, _ LIME --GREENI ora certificate of Worker's Compensation Insurance, or a certified HEATING -VENTILATING-AIR CONDITIONING ' w copy thereof(Sec 3800 Lab C) Policy No " Company COUNTY:OF LOS AN DEPT'OF PUBLIC WORKS rt_ BUILDING AND,SAFETY DIV: . ❑. Certified copy is hereby furnished ❑ APPLICANT - BUILDING department copy Is filed with the county budding mspecuon FOR INT E TO IN A` ADDRESS '1 department, t , ( � Date Applicant LOCALITY NO . TYPE OF APPLIANCE OR EQUIPMENT FEE 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 1. MAP,BOOK' , 5� sy`, PAGE ;!:�11/3 PARCELdc�? permit Is for-one hundred dollars($100)or less) AIR HANDLING UNIT,CFM DISTRICT NO - PROCESSED BY I certify that in the performance of the work for which this permit - is Issued, I shall not employ any person in any manner so as to BOILER,BTU become subject to the Workers'Compensation Laws 40040f r o r 'A 9 �'' VENTILATION SYSTEM -COMPRESSOR,BTU / Date "• ,2 - /lpptfcant / APPROVALS DATE • NSP TOR S S GNATURE " � NOTICE T APPLICANT If, after making,ttiis ertificate of F ROUGH' Z Exemption,you should become subject to the Worker Compensation EVAPORATIVE COOLER provisions of the Labor Code, you,must forthwith'comply with such FINAL provisions or this permit shall be deemed revoked FURNACE FAU GRAVITY //__ LICENSED CONTRACTORS DECLARATION FLOOR BTU (o :` VALIDATION hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT (commencing with Section 7000) of Division 3 of'the Business and WALL Professions Code;and my license is in full force and effect R License Number Y7v Zy__Lic Class S //�/��iTs oa le,7a Contractor // v `'oate o Z V ❑ 'Lam exempt under Sec Plan check fee B&P C for this reason PERMIT ISSUING FEE$ O U Date TOTAL FEE', W, a Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT t N 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 , Code) 1 ADDRESS ,' 's ' I, as owner'of the property, or my employees with wages ff_ ■8 as their sole compensation, will do the work and the CITY TEL NO -,-, structure is not intended or offered for sale (Section 7044, a ` 333 - °�} ■� Business and Professions Code) OWNERS, /.�1/9e�lL-�'/✓ ;BAS'/(,r ' 1 I I t�_ !f ❑ I, as owner of the property, am exclusively contracting MAIL �r m n`, t r with licensed contractors to construct the project (Sec- ADDRESS S G��//��`j T+.+�t1L ;, 95 tion 7044, Business and Professions Code) y " L CITY CONSTRUCTION LENDING AGENCY e � C!Tln / J ' CHANGE I hereby affirm that there is a construction lending agency for CONTRACTOR ' • " t �'llttl'GE the performance of the work for which this permit s issued ALJF (Sec 3097, Civ C) r orf r / rr r tir�" ADDRESS 0 `�IRCY IGG'�IV ��s <,_ 1'tI••, _ Lender's Name /�/�/� n /�� +�V+ I�I�I�i' f' { CITY 2C./7,0/;q 1A94 TFor +_ 15 Lender's Address STATE ^. LIC - 39"�7AN 9:L+ I certify that I have read this application and state that the above LICENSE NO J y CLASS �'2-0 ' Information is correct I agree to,comply with all County ordinances ;J and State la s relate g to building construction,and hereby authorize r' ' represe es Is nt o enter upon the above-mentioned pr or•i ectl r o/ z � SEE REVERSE FOR EXPLANATORY LANGUAGE TORE OF APPLICANT 08 AGENT DATE - ' WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self Insure, or a certificate of Workers' Compensation Insurance, - ` HEATING - VENTILATING -"AIR CONDITIONING or a certified copy thereof (Sec 3800, Lab C ) 76A364C , 991357 Republic 20-0046 DPW 9/88,t , Polley No Company _ COUNTY OF LOS ANGELES BUILDING AND SAFETY ' M Certified copy is hereby furnished r X 0 Certified'-copy Is filed with t 'c unt Ild Inspec FOR-APPLICANT TO FILL IN BUILDING t de art ent ADDRESS 9527 K nnerl P -(PRINT OR TYPE ONLY) Date v 'Applicant NO TYPE OF APPLIANCE OR EQUIPMENT, FEE LOCALITY Temple City ` CERTIFICATE OF'EXEMN FROM W RS' NEAREST 'COMPENSATION INSURANCE CRO55 ST (This section need not be completed if the work IABSORPTION UNIT, BTUnvolved,by � DISTRICT NOPROCESSED BY • 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 �O` •�/ permit Is Issued, I shall not employ any person'in any manner ) J so as to become subject to.the,Workers'CompensationBOILER, BTU-Laws APPROVALS DATE INSPECTORS SIGNATURE • Date ' Applicant ; 1 COMPRESSOR, BTU 0,^� ROUGH !F NOTICE TO APPLICANTt If, after making this Certificate of VENTILATION SYSTEM '' / (T" FINAL t J Exemption, you should become subject to the Workers' r t Compensation provisions of the Labor Code,'you must forth- EVAPORATIVE COOLER VA I CATION with comply with such provisions orgthhis permit shall be deem- • ed revoked E, _�� 5 r FURNACE , FAU GRAVITY _ LICENSEDSCONTRACTORS 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 CL A,ce 221751 t Lic Class-C-20 , r i'n Date8/23/90Q� O m exempt under Sec t t rt Plan check fee v W B dP C for this reason $ 13 00 0. " PERMIT ISSUING FEE . Date . . Z Signature -` - • - TOTAL FEE IOWNER-BUILDER DECLARATION PLAN CHECK APPLICANT B� I herebyyaffirm that I am exempt from the Contractor's License F. Law for the following reason (Section 7031 5, Business and • NAME- Professions Code) I, as owner of, ADDRESS the property,'or'my employees with - s wages as their sole compensation, will do the work and - - ' 't __ =a _the structure Is not intended or offered for sale(Section CITY TEL NO _ 7044, Business and Professions Code) 133�- 'LQ I' OWNER I, as owner of the property, am exclusively,contracting Conrad.-Bai.l,e i ITU' , with, licensed contractors to construct the project (Sec- MAIL tlon_7044, Business and Professions Code) t, ADDRESS 9527 Kennerl'y r I0TAL ..- 21:3' 00 CONSTRUCTION LENDING AGENCY I hereby affirm that there Is a construction lending agency for CITY t em 1 e C1 t TEL NO 285=6073 :r_HEC' the performance of the work for which this permit is Issued ,', CONTRACTORBr ant Heatln & A/C pool (Sec 3097, Civ C ) , ADDRESS Lender's Name 1350 E. Las Tunas Dr. ' CITY - San AbrieI ' TEL N0286-11 41' � �lUtl�-CiCl�� -'/i f•`'ll Lender's Address STATE LIC ^• - -1I).c I certify that I have read this application'and state that the LICENSE NO CLASS C-20 above information is correct I agree to comply with all County o antes and St to lows relating to building construction, nd er au or a representatives of this County to enter po ab entioned pro rt fo6ntion purp ses - I - - • ••• � - - - � - - + - , SEE REVERSE FOR EXPLANATORY LANGUAGE gnature of Applica) Agent Date