HomeMy Public PortalAbout9470 OLIVE ST_Mechanical__ s ' -
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r'�P ,'WERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self APPLICATION FOR PERMIT
insuee, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
CE-81
or a certified copy thereof(Sec. 3800, Lab. C.) C
CE 818(REV. 10/81)
Policy No.—
Y OpyI-W is'Ahe y any TriS.
Certi ied copy is hereby furnish d. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with th coun u'Iding inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ^^ (PRINT OR TYPE ONLY) ADDRESS
9470 GliVe
Date pplicant // t LOCALITY Temple Cit
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST ,L�
COMPENSATION INSURANCE CROSS ST. �y—
(This section need not be completed If the work invol1by ABSORPTION UNIT,BTU 2 DISTRICT NO. �i PROCESSED BY
3
the permit is for one hundred dollars (;100)or less.) AIR HANDLING UNIT,CFM d,I
491)
I certify that in the performance of the work for which this ` V
permit is issued, I shall not employ any person in any mann
so as to become subject to the Workers'Compensatio WS. BOILER,BTU APPROVALS DATE INSP TOR'S SIGNATURE
Date Applicant / COMPRESSOR, BTU ROUGH 1.
NOTICE TO APPLICANT: If, Ver making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should-become subject to the Workers'
Compensation pro�eisii5ns of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N
with comp"fF such provisions or this permit shall be I
deemed revoked. FURNACE: FAU G TY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I'hereby affirm that I am licensed under provisions of Chapter 9SUSPENDED UNIT
f '(commencing with Section 7000)of Division 3 of the Business HEATER: WALL
and Professions Code,and my license is in full force and effect.
= =r ?v O
License Number 43 g 77 58 Lic. Class C 7n ► V
Kinney A/C 9/30/85'
19
Contractor Date V 0
V
I am exempt under Sec. Plan check fee _ 2309.3A
B.&P.C. for this reason' PERMIT ISSUING FEE
Date: # o o o o o 8
TOTAL FEE
Signature 1 - - 49.75
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License Poo for the following reason (Section 7031.5, Business and NAME o . . 4 9.7 5 5)
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS 1 G08-85
wages as their sole compensation,will do the work and CITY TEL. NO.
the structure is not intended or offered for sale(Section
7044, Business and Professions Code).
OWNER K.J. Refill
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). i ADDRESS
saMe
CONSTRUCTION LENDING AGENCY CITY Temple City TEL. NO.
I hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is issued CONTRACTOR Kinney AC
(Sec. 3097, Civ. C.).
Lender's Name
ADDRESS 1441 Anaheim Blvd.
,
CITY TEL. NO.
Lender's Address Anaheim
STATE I certify that I have read this application and state that the LICENSE NO.419758 CLLA.SSC44
above information is correct. I agree to comply with all County
ordinaes nd State laws relating to building construction,
and h eby thorize representatives of this C unty to enter
upon e o e- e.ntione property for i pe ion p1
oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date