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WORKERS'COMPENSATION DECLARATION I 7GA3864C 18 80i lid lid �� dp `� ®�' fid®� i� (� ��j'
I hereby affirm that I have a' certificate of consent to self If'Il— � 611 Ir it uvu u [�
insure,or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec.3800,Lab.C.)
Policy NW 81139$9„JanyFremont Indem.
f COUNTY OF LOS NG /�" I LDING ARID SAFETY
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
department. ADDRESS 710 N. Primrose
Date Applicant (PRINT OR TYPE ONLY)
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY Tem le Citsi-
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE }
.
CROSS ST. O
(This section need not be completed if the work involved ABSORPTION UNIT, BTU p
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. P E 6Y ' V
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM rS Q' cc
permit is issued, I shall not employ any person in any manner C/ o O
so as to become subject to the Workers'Compensation Laws. BOILER,BTU ~
t:7 APPROVALS DATE INSPECTOR'S SIGNATURE W
'Date Applicant COMPRESSOR,BTU �-
ROUGH .--��� / e=-•�, N
INOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEMZ
Exemption, you should become subject to the Workers' FINAL -
i
Compensation provisions of the Labor Code, you must forth- VALIDATION
EVAPORATIVE COOLER
with comply with such provisions or this permit shall be
deemed revoked.
FURNACE: FAU33~�,C.RGIVITY
LICENSED CONTRACTORS DECLARATION 1 FLOOR: BTI(
iI hereby affirm that I am licensed under provisions of Chapteri, HEATER: SUSPENDED UNIT
19 (commencing with Section 7000)of Division 3 of the Busi- WALL
mess and Professions Code, and my license is in full force and
leffect.
(License Number 221751 Lic.Class C20
Contractor Date
IO I am exempt from the licensing requirements as 1 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 $
Lic.or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT t 17 • Q
fI hereby affirm that I am exempt from-the Contractor's NAME
(License Law for the following reason (Section 7031.5, Busi- '
mess and Professions Code): ADDRESS '` 0 1 r 5 F9
I❑ I, as owner of the property, will do the work and theCITY TEL.NO. 0 0 0 0 41 )
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
I❑ OWNER H. E. Bowen ? ° - 27.00
I, as owner of the property, am exclusively contracting
l with licensed contractors to construct the project I MAIL 5710 N. Primrose o 0 °
(Section 7044,Business and Professions Code). ADDRESS
I CONSTRUCTION LENDING AGENCY CITY Tem le City TEL.NO. 286-2679 0611 -81
II hereby affirm that there is a construction lending agency
.for the performance of the work for which this permit is CONTRACTORBryant Heat, & Air Cond
issued(Sec.3Civ. 1350 E. Las Tunas Drive
(Lender's Name
� ADDRESS
I
ILender's Address CIT'San Gabriel TEL.N0286-1141
lI certify that I have read this application and state that the I STATE LIC.
above information is correct.I agree to comply with all County LICENSE NO. CLASS
ordinances and State laws regulating Heating, Ventilating and
it ditionf ,an eby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
Co ity a the above-mentioned property for
ins ec
I
re of Permittee Date 1