HomeMy Public PortalAbout9417 OLIVE ST_Mechanical__ 11LORKEffirCOMPENSATION DECLARATION APPLICATION FOR PERMIT
I h8reby affirm that
that l have a certificate of consent to self
Imsure, or a certificdt0►of'V1L' kers'Compensation Insu?once, • . , HEATING - VENTILATING - AIR CONDITIONING
or.a certified copy thereof(Sec. 3800, Lob. C.)
r89�483405-02 Fremont Indemnity c�-818(REV. 10/81)
❑olicy o. Company
Certified copy is hereby furnished. I COUNTY OF LOS ANGELES BUILDING AND SAFETY
IM Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS 417 W. olive Street
N.E.S. Mechanical (PRINT OR TYPE ONLY)
Date 7-1-91 Applicant�Systems NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY Temple City CA
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed If the work Involved by ABSORPTION UNIT, BTU DISTRICT NO PRO SSED BY
the permit is for one hundred dollars($100)or less.) r /1
AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this
(`/J
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER,BTU APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant 1 COMPRESSOR, BTU I an 000 1200 00 ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAUGRAVITY
LICENSED CONTRACTORS DECLARATION 1 FLOOR BTU 12.00
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect.
550156 Lic. Class C 20 4 Outlets 2:00 each 8.00
License Number Q
NN Fr ee Mechanical S st 1i-90 1 Inlet `� 2.00 each 2.00
'Cbr�ti'&r y 'Date
❑ .I am.exempt under Sec. Plan Check fee
tat
B BP.C. for this reason PERMIT ISSUING FEE$
Date: 13.00
Signature TOTAL FEE 1 47.00
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 _
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and NO. ry
the structure is not intended or offered for sale(Section CITY TEL. ')-17 .3~
7044, Business and Professions Code).
El1,
I, as owner of the property, am exclusively contractingNorm Allen ---, ��
with licensed contractors to construct the project (Sec- MAIL ADDRESS OTA' fir
2220 S. Fairgreen AveAve. -
tion 7044, Business and Professions Code). Lt:'! t;„l_l_
CONSTRUCTION LENDING AGENCY CITY Monrovia TEL. NO 818-446-0944
I hereby affirm that there is a construction lending agency for ti;)i�`{1y;5 ,1Et
the performance of the work for which this permit is issued CONTRACTOR N.E.S. AlechaliLical Systems
(Sec. 3097, Civ. C.).
ADDRESS 518 S. Vermont ve.
Lender's Name
Lender's Address CITY Glendora, 91740 TEL N0 .k
.818-914-5696 _al i Al--iSTATE LIC
I certify that I have read this application and state that the LICENSE NO.550156 CLASS C-20
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
_upo the above- a grope ty for inspection purposes. SEE REVERSE FOR EXPL NATORY LANGUAGE
h-12-90
Signature of Applicant or A, nt Date
i