HomeMy Public PortalAbout5820 PRIMROSE AVE_Mechanical__ WQRYERS'COMPENSATION DECLARATION CEA 86 8C( 2-80) APPLICATION F® • PERM 7
I hereby affirm that I have a certificate of consent to self
insure,.or a certificate of Workers'Compensation Insurance,or HEFTING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec.3800,Lab.C.)
Policy No64-80 JJnyState Comp Ins Fund
r-1 cert ified copy is hereby furnished. COUNTY OF L S A S � UI LDING AND SAFETY
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADORE
department. ADORE 5820 $N Primrose
Date Applicant (PRINT OR TYPE ONLY)
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEEe pe—
COMPENSATION INSURANCENEAREST >-
(This section need not be completed if the work involved ABSORPTION UNIT, BTU-' CROSS ST.. �• O
by the permit is for one hundred dollars (5100) or less.) DISTRICT NO. PROC D BY V
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM �1 > CC
permit is issued, I shall not employ any person in any manner `� 'C/ O
so as to become subject to the Workers' Compensation Laws. BOILRR, BTU H
APPROVALS DATE INSPECTOR'S NATURE W
Date Applicant 1 COMPRESSOR,BTU 3-ton 1 �� ROUGH S''^^ " ����; N
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 VALIDATIO
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAUN— �V ITY
LICENSED CONTRACTORS DECLARATION 1 FLOOR: BTUly1 1 AA 7�
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- WALL
ness and Professions Code, and my license is in full force and
effect.
License Number 221751 Lic.Class C20
Contractor Date
I am ekempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan-check fee 25%Of above.
acting in my.professional capacity (Section 7051, Bus- PERMIT ISSUING FJE .
iness and Professions Code).Lic.or Reg.No. Date TOTAL FEE2 00
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from- the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS
0 1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section CITY TEL. NO.
7044, Business and Professions Code). . z OWNER 3 2 S-3 A
I, as owner of the property, am exclusively contracting e_y A Yo 0 0 0 4
with licensed. contractors to cohstruct the project MAIL 5820 Primrose
(Section 7044, Business and Professions Code). ADDRESS 2 0 - 27.00
CONSTRUCTION LENDING AGENCY CITY Temple I citX TEL.N0.286-7845
I hereby affirm that there is a construction lending agency o 0 0 2.7, 0 0 3
for the performance of the work for which this permit is CONTRACTORynnt Heat & Air Cnnd
issued(Sec.3097,Civ.C.). 1 201 —80
Lender's Name ADDRESS
Lender's Address CITWI'em le City TEL.N2-86-1141
I certify that I have read this application and state that the STATE LIC.
above information is correct.I agree to comply with all County LICENSE NO, rj1 CLASS (✓�0 .
ord' s and State laws regulating Heating,Ventilating and i
Ai Co on' ,an reby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
C uy e e n the abov - entioned p perry for
ins ectio - ur /
Gr
Sign ure o Permittee Date