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HomeMy Public PortalAbout10769 LYNROSE ST_Mechanical__ o L WORKER'S COMPENSATION DECLARATION 20-0048 DPW 9/89 0 ��`� ®[�� ®9 L nCY610 ll 7M364C APPLICATION LIME GREEN I herQby affirm that I have a certificate of consent to self Insure, or a trtificatmV of Worker's Compensation Insurance,or a certified HEATING-VENTILATING-AIR CONDITIONING copy the'rebf(Sec.3800 Lab.C.) 7 a Policy No. P C 9 913 5 Company R e p u b 1 i C I n d e m n i t_V UNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Certified copy is hereby furnis d. CU © Certified co is filed with t e cc u d i action FOR APPLICANT TO FILL IN BUILDING copy ADDRESS 10769 Lynrose Street department. (PRINT OR TYPE ONLY) Date 5/15/91 Applin LOCALITY Temple City NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF E PTION FROM WO S' NEAREST G l i c k m a n CROSS ST. COMPENSATION INSURANCE ABSORPTION UNIT,BTU ASSESSOR (This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to I BOILER,BTU become subject to the Workers'Compensation Laws. 13 0 4 0 0 2� t 0 n 1 5 0 0 �0 COMPRESSOR,BTU 2 APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLERsr provisions of the Labor Code, you must forthwith comply with such FINAL l provisions or his permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION 1 FLOORFURNACE: FAU BTU R y. 15 . 00 VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. License N began 17,5)M' �t Class C-20 i G Contracto A Z9 5/15/91 ❑ I am exempt under Sec. Plan check fee B B.&P.C.for this reason PERMIT ISSUING FEE$ 15 C C Date: TOTAL FEE S451. 00 u 4 Signature U, PLAN CHECK APPLICANT OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law NAME S a 1 Foggia for the following reason (Section 7031.5, Business and Professions ® r.-.T s Code): ADDRESS 10769 Lynrose Street =-aaa ❑ I, as owner of the property, or my employees with wagesw I i as their sole compensation, will do the work and the clrvTempl e City TEL.NO. 446-8007 +`'°'-3 structure is not intended or offered for sale(Section 7044, _j Fi 3 Business and Professions Code). OWNER M r. & Mrs . Sal Foggia i';s N�. r IC- ❑ tea--- a 00 I, as owner of the property, am exclusively contracting MAIL 10 7 6 9 L n r o s e Street r' a r with licensed contractors to construct the project (Sec- ADDRESS y 'CHEC'� tion 7044,Business and Professions Code). CITY Temple City TEL.NO. 446-8007 -fNGE CONSTRUCTION LENDING AGENCY lJ I hereby affirm that there is a construction lending agency for CONTRACTOR the performance of the work for which this permit Is issued Bryant Heating & A/C Inc . (Sec.3097,civ.C.). :)i;i=�_IO[j s , ADDRESS 1350 East Las Tunas Drive ff { Lender's Name CITY San Gabriel TEL.No2 8 6-1 141 Lender's Address I certify that I have read this application and state that the above CET NSE LIC. NO. 2 21 7 51 CLCASS C-20 information is correct. I agree to comply with all County ordinances and State laws relating to building construction,and hereby authorize em aSEE ter upon the above-mentioned REVERSE FOR EXPLANATORY LANGUAGE VA4T515/91 IURE OF APPLICANT AGENT DATE