HomeMy Public PortalAbout9521 OLIVE ST_Mechanical__ I
WORKERS'COMPENSATION UICIARATION A8CE18(2-80) A P P UC AT I®NFOR P E®W
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I hereby affirm that I have a• certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,o'r HEATING-VENTILATING-AIR CONDITIONING
certified copy thereof Sec.3800,Lab.'C.
Policy I 10790077 ompany Ca. Casualty I ndemnli ty �—
Certified copy is hereby Furnished.
COUNTY OF LOS ANGELES / BUILDING AND SAFETY
I
® Certified copy is filed with the county building inspection i FOR APPLICANT TO FILL IN BUILDING
de..}}��artme *. ADDRESS 9521 E. Olive Street
Date L"17 k Applicant E. L. PAYNE COMPANY (PRINT OR TYPE ONLY)
CERTIFICATE OF EXEMPTION FROM WORKERS'
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY Temple City
COMPENSATION INSURANCE NEAREST
CROSS ST. C10verly
(This section need not be completed if the work involved ABSORPTION UNIT, BTU a
by the permit is for one hundred dollars (SI00) or less.) DISTRICT NO. PROCESSE- BV r U
I certify that in the'performance of the work for which this AIR HANDLING UNIT,CFM ,r�
permit is issued, I shall not employ any person in any manner (� cc
so as to become subject to the Workers' Compensation Laws. BOILER,BTU O
APPROVALS DATE INSPECTOR'S SIGNATURE V
Date Applicant 1 COMPRESSOR,BTU 1 00 ROUGH W
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEMFINAL �o?' �-� I— t-J Z
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: FAUX— C11�V1(T) _ 15 00
LICENSED CONTRACTORS DECLARATION 1 FLOGR: BTU--L------%-
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT r
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and 7,10"-7J
effect.
License Number—M-22-8 Lic.Class C-20
Contractor E. L. PAYNE Date 2-17-82
E] I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$ $ 50
Lic.or Reg.No. Date TOTAL FEE $ 0
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from- the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS
I, as owner of the property, will do the work and the CITY TEL. NO.
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
❑ OWNER t 3 0 1,8 A
I, as owner of the property, am exclusively contracting lL1 S9
with licensed contractors to construct the project MAIL
(Section 7044,Business and Professions Code). ADDRESS 9521 E. 01 ive Street . c c c o 8
CONSTRUCTION LENDING AGENCY CITY Temple City TEL.NO. 286-0239 2 " 3a50
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is =CONTRACTOR •o „ o r xp pE L PAYNE COMPANY , 3 8... C
issued(Sec.3097.Civ.C.).
Lender's NameADDRESS 166 W. Live Oak Avenue
0222-82
Lender's Address CITY Arcadia TEL.NO. 446-611$
I certify that 1,have read this application and state that the STATE1 2022$ LIC. C�20
above information is correct.I agree to comply with all County LICENSE NO. CLASS
ordinances and State laws regulating Heating. Ventilating and
Air Co boning,and he y authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
C un to ente{ upo ie above-mentioned property for
ion purposes.
t 2-1 -82
i nature of Perm' ee Date