HomeMy Public PortalAbout5745 PRIMROSE AVE_Mechanical__ it , • I , 4
WORKERS'COMPENSATIQ+N DECLARATION a 'l y CE 36,4C q, P P p �,f+ fA ® fis'®� Iii fly fid f�Ll �T
r CE-8'18(�:$,0) ' i=l L� N�6=a If- Ir E R 0711
I hereby affirm that I have a' certiftcat�bf consynt to self i
insure,or a,certificate of Workers'Compensation Insurance,9r HEATING-VENTILATING-AIR CONDITIONING
a rectified copy thereof(Sec.3800,Lab.C.) I 'fl
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Pokey ND. 4 4 2 5 8 6ompany State Fund
4 COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection BUILDING
de artment. FOR APPLICANT TO FILL IN INDDRESSj r rimrose Ave.-
Datee�U84plicant AAA Cond. Air, Inc (PRINT OR TYPE ONLY)
LOCALITY Q
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE Tem l It
COMPENSATION INSURANCE NEAREST
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. Las Tunas
by the permit is for one hundred dollars ($100) or less.) ` f` V
DISTRICT NO. v PROCESSED YA*-,4
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued,.1'shall not employ any person in any manner O
so as to becomesubject to the Workers' Compensation Laws. BOILER,BTU I—
O APPROVALS AT INSP CTOR'S 51 A RE W
Date Applicant , 1 COMPRESSOR BTU -, ./ d
ROUGH N
NOTICE TO APPLICANT: If, after making this Certificate ofVENTILATION SYSTEM FINAL Z
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- j EVAPORATIVE COOLER. VALIDATION.
with comply with such provisions or this permit shall be C , -
deemed revoked. ' FURNACE: FAU
LICENSED kAAVJ��G.—
CONTRACTORS DECLARATION 1 FLOOR: BTU ( i U U a
I hereby affirm that I am licensed under provisions of Chapter 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
effect.
License Number 293529 Llc.Class C20 pp
Contractor AAA Air Date 11/28/84 # g b Q tl
ElI am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer 1 Plan check fee 25%of above. I ° ° 3 Q 5 0
acting in my professional capacity (Section 7051, Bus-
inessPERMIT and Professions Code). l e o 0 3(15 0 5
Lie.or Reg.No. Date TOTAL FEE 0�(� 1,2 9=8 4
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that 1 am exempt from- the Contractor'sI NAME
License Law for the following reason (Section 7031.5, Busi- I
ness and Professions Code): ADDRESS
,1
I, as owner of the property, will do the work and the TEL. NO.
structure is not intended or offered for sale (Section CITY
7044,Business and Professions Code). ;
❑ j OWNERChiincr
I, as owner of the property, am exclusively contracting .1
with licensed contractors to construct the project I MAIL
(Section 7044,Business and Professions Code). ADDRESS 574 NorthPrimrose mrose Ave.
CONSTRUCTION LENDING AGENCY I CITY Temple City TEL.N0.282-4652
I hereby affirm that there is a construction lending agency CONTRACTOR
for the performance of the work for which this permit is
issuedSec.3097,Civ.C.).
Lenders Name ADDRESS in 16 o
Lender's Address i CITY TEL.NO.
El Monte 579-1800
1 certify that I have read this application and state that the :jSTATE LIC:
above information is correct.I agree to comply with all County HLICENSENo. 293529- CLASS C20
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter up the above-mentioned property for X
inspection purposes.
av� 11
T] 128184
Signature of Permittee Date
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