HomeMy Public PortalAbout5575 NOEL DR_Mechanical__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm thaw I have o'certificat� ofconsentto self
ora ertifiedcopy thereortificate off(SecWorkers 3800 ob Iqn Insurance 76A364C HEATING - VENTILATING - AIR CONDITIONING
CE 818(REV 10/81) -
PoNo M WOG1 1(e ,�Ty SZ1PA�].A�' N21:.
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑X Certified copy is filed with the county building inspec FOR APPLICANT TO FILL IN BUILDING
tion dartment ADDRESS 5'575 OCL
9/115/88 Alberts Inc. (PRINT OR TYPE ONLY) I LOCALITY
Date Applicant '�
CERTIFICATE OF EXEMPTION FROM WORKERS No TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST ^. '
I I COMPENSATION INSURANCE CROSS ST /
(This section need not be completed if the work Involved by ABSORPTION UNIT BTU DISTRICT NO PROCESSE
the permit is for one hundred dollars(:100)or less) AIR HANDLING UNIT CFM �^ (1
1 certify that in the performance of the work for which this c
permit is issued I shall not employ any person in any manner BOILER BTU
so as to become subject to the Workers Compensation Laws APPROVALS DATE INS OR S SIGNAT
Date Applicant COMPRESSOR BTU ww,A� Q- 0 ROUGH
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM I FINAL
Exemption you should become subject to the Workers
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER ATION
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU GRAVITY -
LICENSED CONTRACTORS DECLARATION , FLOOR BTU —�
1 hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT—
(commencing
USPENDED 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
License Number 5JR961 Lic ClassY20 ► � 1V
Contractor. Al lfAr t 4 Imo•date Q�1 Q SRR 0
O
❑ I am exempt under Sec _ W
Plan check fee y
B 8P C for this reason PERMIT ISSUING FEE$ Z
Dote
Signature TOTAL FEE
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor s License , &0 8,14 A
Law for the following reason (Section 7031 5 Business and NAME Joan Conte
Professions Code)
I as owner of the property or my employees with ADDRESS5575 Noel
#° °i° ° ° 8
El
wages as their sole compensation will do the work and CITY Temple City ' TEL NO 309-9677 ► ° - 3G50
the structure is not intended or offered for sale(Section
7044 Business and Professions Code) OWNER ° ° ° 3 Q 5 0 5
Elas owner of the property am exclusively contracting JOan Conte
with licensed contractors to construct the project (Sec MAIL
tion 7044 Business and Professions Code) ADDRESS5575 Noel003-88
CONSTRUCTION LENDING AGENCY CITY 'TEL NO
I hereby affirm that there is a construction lending agency for rp PMPI P (,,.I ty 309-9677 ►
the performance of the work for which this permit is issued CONTRACTOR Alber'S Inc.
(Sec 3097 Civ C )
ADDRESSF., Ramnna L - -
Lender's Name
14617 Lender s Address CITY Baldwin Park TEL NO 960-1868
1 certify that I have read this application and state that the LICENSE NO 18 61, C TATE ASS 0-20
above information is correct I agree to comply with all County
ordinances and State jaws relating to building construction
and hereby authorize representatives of this County to enter - -
on the oboe mentioned property for insp ction j urposes SEE REVERSE FOR EXPLANATORY LANGUAGE
ocy - - r
Signatur f Applicant or Agent Date D b