HomeMy Public PortalAbout9539 PENTLAND ST_Mechanical__ IV. WORKERS'COMPENSATION DECLARATION
�.,.I hefel+Y offi,sn that I have a certificate of consent to self #40722 APPLICATION FOR PERMIT
insure, or a certificate of Workers' Compensation Insurance, C E-81 HEATING - VENTILATING - AIR CONDITIONING
a tified copy thereof (Sec. 3800 Lab. C.
6���79 CA STAT E �UN D CCE 818(REV 10/81)
Policy No. Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
® Certified copy is#iled with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS 9539 Pentland Street
Date 7-22-85 Applicant E. L_ PAYNE LOCALITY Temple C i tY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST Al l esand ro
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO PROCESSED BY
the permit Is for one hundred dollars($100)or less.)
AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. IBOILER, BTU APPROVALS DATE INSPECTOR'S SIGN URE
Date Applicant 1 COMPRESSOR, BTU 10 00 ROUGHA-11 At L
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAUX _GWIT6
LICENSED CONTRACTORS DECLARATION FLOOR BTU / +U0— 10 00
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect. A.
License Number 120228 Lic. Class C-20 ► V
Contractor E. L. PAYNE Date 7-22-85_
❑ I am exempt under Sec. M
Plan check fee IIL
�
B.BP.C. for this reason �
Date: PERMIT ISSUING FEE$ 10 50
Signature TOTAL FEE 0 50
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's Licensepoll #� 8 7 Z 6 u
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 CITY TEL NO I o o 3 U 5 r)
the structure is not intended or offered for sale(Section
7044, Business and Professions Code).
El _'
OWNER I, as owner of the property, am exclusively contracting MS R. DU 5`
C C er o�o o J
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MAIL
with licensed contractors to construct the project (Sec- ADDRESS Pentland Street
tion 7044, Business and Professions Code). () 22-05
CONSTRUCTION LENDING AGENCY CITY Temple Cit TEL NO 286-8454
I hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is issued CONTRACTOR E. L. PAYNE COMPANY
(Sec. 3097, Civ. C.).
ADDRESS 148�3 Ca 1 i fa Street
Lender's Name
Lender's Address CITY Van Nuys TEL NO 793-1131
STATE LIC.
I certify that I have read this application and state that the LICENSE NO 120228 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
Pon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
7-22-85
Signature of Applicant or Agent Date