HomeMy Public PortalAbout5019 PAL MAL AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby af#irrg, that.,l leave a 2�rtificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, �6A364C HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C.) E-818(REV. 10/81)
P❑olicyNo. PC9914�ampa, epublic Indemnitcy
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
EaXCertified copy is filed with th my uild' g inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS 5019 Pal Mal
(PRINT OR TYPE ONLY)
Date /27/90 Applicant LOCALITY Temple Cit
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPT FROM WOR NEAREST
COMPENSATIO INSURANCE CROSS ST. Da3-nes
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT PROC BY
the peit Is for onehundred dollars($100)or less.) /
I certifythat in the performance of the work for which this AIR HANDLING UNIT,CFM !—
permit is issued, I shall not employ any person in any manner BOILER,BTU
so as to become subject to the Workers'Compensation Laws. APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant One COMPRESSOR, BTU 3 6 ,n n n btl7 ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER %14LIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU X _GRAVITY 12 00 ' /(
LICENSED CONTRACTORS DECLARATION One FLOOR _BTMQ QQQ
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect.
Rep ace furnace, ductwork and O
License Numb Lic. lass C-20 a air con 1 loning- 18 00 , U
Contractor Date 1 /7 7 /Q n O
t—
❑ lam 4xempt under S W
Plan check fee D_
B.B,P.C. for this reason PERMIT ISSUING FEE$
Date:
Signature TOTAL FEE /
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
v
Professions Code): �,�,� a
El1, as owner of the property, or my employees with ADDRESS At"CT-®r
wages as their sole compensation,will do the work and CITY TEL. NO. -3 cr
the structure is not intended or offered for sale(Section - U'UOG
7044, Business and Professions Code). OWNER1 ITEM.
ElDezwaan I, as owner of the property, am exclusively contracting 5I>=
with licensed contractors to construct the project (Sec- MAIL TOTAL A�- 5_0113
tt
tion 7044, Business and Professions Code). ADDRESS 5019 Pal Mal 'CHECK cr°[)fl
CONSTRUCTION LENDING AGENCY CITY I Temple City TEL. No. 443-1938 -i
1 hereby affirm that there is a construction lending agency for CHANGE .012
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRES s Drive tibIGl=1—Gc�1 �AN100.32 Va9IKI
Lender's Name :���$ 1 Lender's Address CITY San Gabriel CA TE`' NO286-1141
STATE- LIC.
I certify that I have read this application and state that the LICENSE NO. 221751 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
uyre.f"Appl
e- ioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Siicant gent Date