HomeMy Public PortalAbout9127 LAS TUNAS DR_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C
CE $18 (2-80)
I hereby affirm that I have'a certificate of consent to self
- - G=�1(- lam:h 0�li-�1���tl�l FOR .Ir" lC UIC ILVIt ��.
insure,or a certificate of Workers'Compensation Insurance,or HEATING-V ENTIL.ATING-AIR CQ NDITIOR'lONG ,
a certified copy thereof(See. 3800,Lab-C.)"
Poli cyl33 26 „ 9any Fireman ' s Fund `
Certified copy is hereby furnished.. COUNTY OF LOS ANGELES - 6U1 LDING AND SAFETY .
❑' Certified copy is filed with the county building inspection FOR;APPLICANTO FILL' IN BUILDING
department. ADDRESS 91,27 Las ' Tunas Drive
Date Applicant (PIRINT OR TYPE ONLY)-
CERTIFICATE OF EXEMPTION FROM WORKERS' iANCE EOUiPMENT .
FEE LOCALITY Temple .City .
NEAREST
(This section need n not completedIR f the work involved ABSORPTION UNIT,BTU }
NO. TYPE O 'A PL
COM
CROSS ST. G.
by the permit is for one httndred dollars ($100) or'less.) DISTRICT NO. PROLES. -D BY (�
I certify that ;n 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. ��
so as to become subject'to the Workers Compensation Laws. BOILER,BTU
- - - - - APPROVALS DATES INSPECTOR'S SIGNATURE L)
- Date Applicant COMPRESSOR,BTU_5.7._Q0_0_' 10 00,. ROUGH y CL
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM _ 2
Exemption, you should' become subject to .the„Workers' FINAL
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions'or this permit shall be
deemed revoked.
FURNACE: FA U %gpVlTy_ •`��
LICENSED CONTRACTORS DECLARATION Z FLOOR: - BTU _t5_�QU.� �.0 CC �1
I hereby affirm that I am licensed under provisions of-Chapter' HEATER: SUSPENDED UNIT �Lj� p
9 (commencing with Section 7000)of Division 3 of the Busi- WALL (/
ness and Professions Code, and my license is in full force and
effect.
355868 C-2p
License Number Lit.Class
Mechanical 3/29183,
Contractor EYi'e Y S Date
I am exempt from the licensing requirements as I am a
licensed architect or'a registered .professional `engineer Plah cheek fee 25%'of.above."
acting. in my profes§ional capacity (Section 705 f, Bus- _.
iness and Professions Code): PERMIT ISSUING FEE.� l� 50
Lie.or Reg.No. Date TOTAL FEE 30 50•
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT '
I hereby affirm that I am exempt from-the Contractor's NAME 1 8 6,1 (�
License Law for=the following reason (Section 7031;5, Busi-
ness and Professions Code): ADDRESS # o o'o 0 0 8
Q I, as owner of the property, will do, the work and the CITY TEL. NO. to`o
structure 'is not intended or .offered for sale (Section 2 , 30,5 Q
7044, Business and Professions Code). f
OWNER," ,Joe Marchi6a fo o`0 3 _
I, as.owner of the property, am exclusively contracting_. t a �},BaE}
With licensed contractors to construct the project MAIL . ^
(Section 7044, Business and Professions Code).
AQOREss.9127 Las Tunas Drive Q511 0;-83U
CITY` TEL.NO,
CONSTRUCTION LENDING AGENCY ; imp 1'e C 1 ty
I hereby affirm that there is a construction lending agency- ' CONTRACTOR 4
for the performance'of the work for which this permit is,
issued (Sec.3097,Civ:C.). r M"e-chani=c.a-l—En-e-rgyr—S_y_s t:' s"
Lender's Name ADD RES516025 .Robin .Way
Lender's Address TEL.NO 3 3 6=L2L8
ridus-txy'
I.certify that I have read this application and state that the STATE LIC.
above information is correct.I agree to comply with all County LICENSE'NO. J 5 H6_8 CLAS5 C-,20
ordinance State. laws regulating Heating, Ventilating and
Air itioninl and hereby u horize representatives of this SEE REVERSE FOR.EXPLANATORY LANGUAGE
o nt, to ent,r up th ove-me tioned property for
ii ec on'iurp,ses.
3/29/83
Ignature of Permittee Date _ _..