HomeMy Public PortalAbout5024 PAL MAL AVE_Mechanical__ WORKERS'COMPENSATION'DECLAR4.TION r, - 70'k g g(280) ��s ®p�I .FORLS ��
I hereby affirm that I have a• certificate of consent to self r
insure,or a certificate of Workers'Compensation Insurance,of I I I���IW(y_NO=iVTILATIIbG-A16a CONDITIONING
certified c i r of(Sec.3800 Lab.C.)
PrYA �+� zenith C.,Policy No. Company
El Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
s
ED Certified copy(s filed ' the county-building inspection � FOR APPLICANT TO FILL IN BUILDING
Date� �%?/ Applica (PRINT OR TYPE ONLY) ADDRESS
024 N. Pal Mnl
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY Temnle C�
CERTIFICATE OF MPTION F ORKERS' .y, r
COMPE ATIOty
N INSUR CE ,I NEAREST
(This section need not be completed if the work involved S ABSORPTION UNIT,BTU CROSS ST. O
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSED Y V
1 certify that in the performance of the work for which this i AIR HANDLING UNIT,CFM ` fY
person in any manner e�
permit is issued, I shall not employ any' ,. C
so as to become subject to the Workers'Compensation Laws. BOILER,BTU
Date Applicant 1 1 3�ton 1 00 APPROVALS DATE INSPECTORS SIG NATURE
COMPRESSOR,BTU ROUGH "•fQ"' - �Z„�` I.�f N
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM Z
Exemption, you should become subject to the Workers' FINAL
Compensation provisions of the Labor Code, you must forth- t EVAPORATIVE COOLER VALIDATION
deecomply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU_- GEiAVITY
LICENSED CONTRACTORS DECLARATION 1 FLOOR: B 10 00 '
I hereby affirm that I am licensed under-provisions of Chapter ' i HEATER: SUSPENDED UNIT
9 (commencing with Section 7000),of Division.3 of the Busi-. I WALL
ness and Professions Code, and my license is in full force and
f
ZA-to -AA
L cense Nu er 221751 Lic.Class C'20 f/l v
Contracto Date
❑ I exempt the licensing requirements as I am a i
licensed archi act or a registered professional engineer II Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$ 10 50
Lic.or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION ' PLAN CHECK APPLICANT
I hereby affirm that I am exempt from-the Contractor's . NAME ";:? �j 0 A
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS 0 0 e c o g
❑ I, as-owner of the property, will do the work.and the I CITY TEL.NO. t
structure is not intended or offered 'for sale (Section _ �- •� �! F['�.-
7044,Business and Professions Code).
❑ OWNER , o :i,C
-
I, as owner-of the property, em exclusively contracting u M S
CI
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code).
ADDRESS •- r• v
CONSTRUCTION LENDING AGENCY CITY Temple City TEL.N0444-0948
I hereby affirm that there is a construction lending agency CONTRACT0Bryant
for the performance of the work for which this permit is
issued Tec.3097,Civ.C.). r•
Lenders Name ADDRESS1350 E. Las Tunas Drive
Lender's Address 'i
clTrSan Gabriel TEL NO 2.86-1141 `
I certify that I have read this application and state that the STATE 221751LIC' C20.above information is correct.I agree to comply with all County - LICENSE NO. CLASS
ordinances and State laws regulating Heating,Ventilating and
.'Air Conditioning;and hereby authorize representatives of this "'i SEE REVERSE FOR EXPLANATORY LANGUAGE -
Co t to r poll the above-mentioned operty for P
in ect' p r 41
• S' t o, mit Date ! .