HomeMy Public PortalAbout6506 OAK AVE_Mechanical__ WORKERS'C'OMPENSAI ION DECLARATION 76A364C g� ��pp p�
I hereby affirm that I have a certificate of consent to self CE-818(2-80) A P P pp L� CAT 0 O u� FOR P E R M PT 4/29/81 29/81
insure, e a certificate of Workers'Compensation Insurance,or HEATING-V ENT ILATING-Alla CONDITIONING ,L
a certifiedOcwvii eof(Sec.380 -t Pb � C LI
Policy No.—7 Company
Certified copy is hereby furnished. I COUNTY OF LOS A GEL ~^ BUILDIftIG AND SAFETY
��.-i-moi
�( Certified copy is filed with the count} hu,ding inspection FOR APPLICANT TO FILL IN BUILDING
�j� 06, forth Oak
Date d1097$1 Applicant BARNES BIG A AIR--CONDITIONING, (PRINT OR TYPE ONLY) ADDRESS
LOCALITY Temple Cit
CERTIFICATE OI EXEA1PT10N FROM WORKERS' I NO. TYPE OF APPLIANCE OR EQUIPMENT FEE y
COMPENSATION INSURANCE NEAREST
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. a
by the permit is for one hundred dollars (5100) or less.) DISTRICT NO. PR o SSEDAY V
1 certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner l
so as to become subject to the Workers'Compensation Laws. BOILER, BTU A O
i ,f TU Q00 APPROVALS DATE INSPECTOR'S ATURE V
Date Applicant COMPRESSOR,8ROUGH a
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL �� Z
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- I EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU ITY ,
LICENSED CONTRACTORS DECLARATION FLOOR: TU RAVL%(!�'
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED NIT �f�!�.
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ncss and Professions Code, and my license is in full force and
effect.
License Number. 257573 C-2U
Lic.Class
Contractor BARNES STG 86AIR CONDMONUG •
0 1 am exempt from lh*e licensing requirements as I am a
licensed architect or a registered professional engineer I Plan Check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$ `
I \
Lic,or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from- the Contractor's NAME HER EV ARDS
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS 406 Genoa
1, as owner of the property, will do the work and the CITY TEL # o o 0 o o $
structure is not intended or offered for. sale (Section .NO. 9. 9
7044, Business and Professions Code). 2 0 o37.00
❑ i
I, as owner of the property, am exclusively contracting OWNER =
with licensed contractors to construct the project MAIL o 0 0 3'7,0 0 5
(Section 7044,Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL.NO. 0a21 -81
I hereby affirm that there is a construction lending agency CONTRACTOR 6 AIR COND T Q IN6�
for the performance of the work for which this permit is
issued(Sec.3097.Civ.C.).
Lender's Name ADDRESS
.712- North Laren Avenge
Lender's Address CITY AZUSA ALIFORNEL NO. 337-6732
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. 257573- - CLASS C-20
ordinances and State laws regulating Heating, Ventilating and
Air Condi ' g, : 1 hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
Cou , to e r pon the above-mentioned properly for
pecti p :s.
Signature of Per ttee Date