HomeMy Public PortalAbout9155 OLIVE ST_Mechanical__ 4•`- ' - WORKER'$.COMPENSATION DECLARATION 240048 DPW 9189 ; LIME GREEN,
�W64C APPLICATION FOR PERMIT
LIME hereby affirm that I have a certificate of consent to self insure, I
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
PC943321 Republic
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
p❑ Certified copy is hereby furnished.
P9 Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
ADDRESS 9155 E. Olive St
department. (PRINT OR TYPE ONLY)
Date 11/01/93 Applicant Air Tro, Inc. LOCALITY Temple City
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS
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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU v�v
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensationr/1
EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL /
provisions or this permit shall be deemed revoked. FURNACE: FAU G VITY _ff3 VALID TION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is In full force and effect.
License Number 25822$ Lie.Class C20
13
Contractor Air Tro, Inc. Date 12/31/93 5� C
❑ I am exempt.under Sec. Plan Check fee C
B.&P.C.for this reason PERMIT ISSUING FEE$ zl 7 F
Date: TOTAL FEE / op
Signature PLAN CHECK APPLICANT (1
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law NAMEAYr T r 0, Inc
, t+
for the following reason (Section 7031.5, Business and Professions .
Code): ADDRESS 1630 SACC_AL
❑ I, as owner of the property, or my employees with wages S. Myrtle u �� 71«5
t
as their sole compensation, will do the work and the CITY TEL.NO. _ ht
structure is not intended or offered for sale(Section 7044, 818 _5311 1 I I EMS
Business and Professions Code). OWNER
❑ 1, as owner of the property, am exclusively contracting MAIL Dicus, Mike TOTAL 71.25
with licensed contractors to construct the project (Sec- ADDRESS HECK 71.25
tion 7044,Business and Professions Code). 9155 E.
CITY Temple City TEL.No($1$) 281-763
CONSTRUCTION LENDING AGENCY CHANGE ■011
I
hereby affirm that there is a construction lending.agency for CONTRACTOR ,
the erformance of the work for which this ermlt s issued Air Tro InC.
(Sec.3097,Civ.C.).
ADDRESS � '8 $]-$ 7-5311 13000-000111/12/92
Lender's Name 64.56 1 PH ri 03,
CITY TEL.NO.
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. S CLASS
Information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representat' of this County to enter upon the above-mentioned
prop y, purp SEE REVERSE FOR EXPLANATORY LANGUAGE i
SIG TURE OF PPLICANT OR AGENT DA7 6