HomeMy Public PortalAbout9588 LOWER AZUSA RD_Mechanical__ 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 e tified copy thereof (Sec 3800 Lab C ) 76AWC
�� ? / +t�j � E 818(REV 10/81)
Polity No O y�2 Compar yf 3 T
Certified copy Is hereby furnished IV0 COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy Is filed with the cou building i9spec FOR APPLICANT TO FILL IN BUILDING
tion epartment (PRINT OR TYPE ONLY) ADDRESS 9588 Lower AzusaRoad
Date Applicant —__ LOCALITY T City, Calif
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
ERTI KATE OF EXEMPTION FROM WORK NEAREST
COMPENSATION INSURANCE CROSS ST Temple C
(This section need not be completed if the work Involved by ABSORPTION UNIT BTU DISTRICT NO PROCESSED BY
the permit is for one hundred dollars($100)or less) ��
I certify that in the performance of the work for which this AIR HANDLING UNIT CFM
permit is issued I shall not employ any person in any manner BOILER BTU
so as to become subject to the Workers Compensation Laws D11II!h APPROVALS DATE INSPECTOR S SIGNATURE
Date Applican} COMPRESSOR BTU ROUGH —/— Qf ��
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL
Exemption you should become subject to the Workers
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be / G O�v ✓ ✓
deemed revoked FURNACE F GRAVITY
LICENSED CONTRACTORS DECLARATION i FLOOR BTU
I hereby affirm that 1 am licensed under provisions of Chapter 9SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business HEATER WALL
and Professions Code and my license is in full force and effect y'
/�� U o c
License Number Lic Class Cl _ ► V
OC
Contractor ate
❑ I am exempt under Sec W
Plan check fee IL
H
B&P C for this reason
Date PERMIT ISSUING FEE$ d' S' Z
13111-0
Signature TOTAL FEE
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 Arthur .Ka iwara
Professions Code) '
❑ I as owner of the property or my employees with ADDRESS 220 5 Troy Avenue
wages as their sole compensation will do the work and
the structure is not Intended or offered for sale(Section CITYMnnt TEL NO 686-0800 8 6 9 4 R
7044 Business and Professions Code)
OWNER David E Parra ' ' ' ' ' $
El as owner of the property am exclusively contracting MAIL
with licensed contractors to construct the project (Sec ADDRESS rj' D 2 • • 3&5 0
tion 7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY CITY El Monte TEL No 448-3141 • • • 3 8 5 0
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is Issued CONTRACTOR ► • ) 230-82
(Sec 3097 Civ C )
Arthur Kajiwara
ADDRESS
Lender s Name
CITY E, TEL NO 686-0800 0 OC� 0
Lender s Address
I certifythat I have read this application and state that the STATE LIC
pp LICENSE NO CLASS C-20
above information Is correct I agree to comply with all County
ordinances rind State jaws relating to building construction
and here authorize repress tives of this County to enter
upo e o e mentio operty for inspection urposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of App / ygent Date