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HomeMy Public PortalAbout9464 LEMON AVE_Mechanical__ VJQRKER'S COMPENSATION'DECLARATION 6 DPW 9/89 APPLI'CATiON FOR PERMIT, . 76A36 '•,I hemuy affirm that I have a certificate of consent to self Insure, 76A364C L1MF,qREE,N , or a certiflcatE+,of'Worker; Compensation Insurance,-or a certified '? HEATING-_VENTILATING -`AIR CONDITIONING' copy thereof(.�ec 3800 Lab C) "' ; a ;3 g� i9T FvN� Policy No Company COUNTY•OF LOS ANGELES, '.' ;'sDEPT OF PUBLIC•WORKS BUILDING AND SAFETY DIV.- Certrfied copy Is hereby furnished Ie�lv Certified copy is filed with the county building in I FOR APPLICANT TO FILL IN BUILDING s •••. e e (PRINT ORTYPE•ONLY) ADDRESS 4 ;-n i• *s LOCALITY' :Date Applicant NO TYPE OF APPLIANCE OR EQGIPMENT r FEE r r• NEAREST CERTIFICATE OF EXEMPTION FROM RKERS' CROSS ST' COMPENSATION INSURANCE ABSORPTION UNIT,BTU (This section need not be completed if the work irivolved b the ASSESSOR' P y '- ,-t;'•• MAP BOOK PAGE PARCEL. • permit is,for one hundred dollars($100)or less.)„ :AIR HANDLING UNIT,CFM DISTRICT NO S PRocesseDBv , I certify,that in the performance of the work for which this permit Is Issued, I shall not'employ any person in'an manner so as to ' _ Y BOILER BTU ' f A become subfect to the Workers''Comperisation Laws �Y7�00,O C "T'�YYiliJ��' COMPRESSOR,BTU - _ I APPROVALS " DATE INSP TOR'S SIGNATURE Date Applicant VENTILATION SYSTEM ' NOTICE,TO'-APPLICANT If,-after makirig"this Certificate of _ ROUGH Exemption,you should become'sublect to the Workers',Compensation EVAPORATIVE COOLER { FINAL provisions-of the,Labor Code, you must forthwith comply with such provisions or this permit�shalllbe deemed revoked' ' FURNACE vFAU oiK GRAVITY' ~ LICENSED CONTRACTORS,DECLARATION FLOOR ' BTU a, VALIDATION -ALhereby affirm that I am Ilcensed under provisions•of Chapter 9 SUSPENDED -UNIT (commencing with Section 7000),ofDivision 3 of the Business and HEATER WALL • Professions Code, ahclmy,hcense is in,full force and effect t Iwo = Re�� (A�tins License-Numberw +Lic'Class rj0 Contractor� Z=��3+� �+�! Date �� , ` r 0 ❑ I am exempt under'Sec Plan Check fee V B&P,C for this season "` _ PERMIT ISSUING FEE$ C00 • ; w y U ' -Date - TOTAL FEE. �' ©D F W a Signature - `- ' PLAN CHECK APPLICANT - ,4 OWNER-BUILDER,DECLARATION ,f, _ s 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 Cocle) a '`'• ADDRESS ' ' t " Sc I;as owner of,the'property, or my employees with wages, °s _, as their sole`'compensation,+wilI'do the'work and the CITY` �Q /� TEL NO -�, structure is not Intended or offered for sale (Section 7044, G•v ° v r f °01 BAiness and Professions Code) '` OWNEREl - r, E- I, as owner ofAhe property,am exclusively contracting MAIL with licensed contractors to construct the project'(Sec- ADDRESSq y� +fL tion 7044,Business and Professions Code) f�.�') j — CONSTRUCTION LENDING AGENCY CIT Ok �. '` TEL NO '82 J1�� -e :•1 s 3�•�. " ' 1 I.hereby affirm that there is a construction lending agency for _,l-f IfL�L - 00 the performance of the work for which this permits'issued CONTRACTOR ' f/'�� °- (Sec 3097, Civ C) *r J ' ADDRESS Lender's Name t 1 l 4 Lille,-1-11301 CITY ESN }OrC f- I, .i Ji e - t° [ 'Lender's Address STAT `n, ^ i ('certify that( LIC ,have read this application and state that the above L CENSE NO" (01OU I0 CLASS+ If I n information is'correct .l 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 pro arty for inspec on'pu oses SEE REVERSE FOR EXPLANATORY LANGUAGE,". ' % ` SIGNATURE OF 4JPLICANTos AGE ,DATE ', _ ^y ,- `�•�' -J•• ' 76A364E (CE'81SA)_„/76 APPLICATION FOR PERMIT y, HEATING - VENTILATING - AIR CONDITIONING COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION FOR APPLICANT TO FILL IN SBUILDING (PRINT OR TYPE ONLY) ADDRESS 464 E. Lemon NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY Tem 1 City NEAREST CROSS ST Trelawney Aye,. ABSORPTION UNIT,BTU OWNER dM r c______--_ ._W i 1 1-1_afi—r)i-,n Ca- AIR HANDLING UNIT,CFM MAIL ' ADDRESS - aS� - BOILER,BTU 'CITY TEL NO Temple City 1 COMPRESSOR,BTU 36-P000 0 CONTRACTOR E L PAYNE -COMPANY VENTILATION SYSTEM ADDRESS 166 W. Live Oak I EVAPORATIVE COOLER CITY Arcadia TEL NO 446-r 1 L FURNACE FAUX GRAVITY-60STATE LIC 1 FLOOR BTU 07. 50 LICENSE NO CLASS _ HEATER SUSPENDED UNIT— DISTRICT NO GROUP ZONE PRO ESSED BY WALL / INSPECTION RECORD d O 3 Nt O c�sN�Civs.4`-T L %u S Im O Plan check fee 25% of above PERMIT ISSUING FEE$ 4 50 lz TOTAL FEE $19 1 50 PLAN CHECK APPLICANT NAME ADDRESS CITY TEL NO - IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL ORDINANCES AND LAWS REGULATING HEATING, VENTILATING, AIR CONDITIONING I HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION•OF APPROVALS DATE INSPECTOR'S SIGNATURE CHAPTER 9, DIVISION 3, OF-THE BUSIN A •PROFESSIONAL CODE ROUGH OF THE STATE OF ORNIA SIGNATURE FINAL OF PERMITTE PLAN CHE VALI ATION CK MO CASH PERMIT VALIDATION ' cK, n+o 1 CASH WORKERS GOMplriV'--ATl0N 7 2 r"'MAR 1 41. 0, 9.5 0 POLICWHOLDER: % r — POLICY NUMBER: ©s