HomeMy Public PortalAbout6323 PRIMROSE AVE_Mechanical__ NtiORK1'R5'CO\1PFNSATION DIsC1.ARATION 7GA8 8C(2-80) FOR OR PGf MIT
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Co pensatiunAin%urace,or HEATING-VENTILATING-AIR CONDITIONING
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Policy`Wri. Ctfrtlpan' --��
/ COUNTY OF LO AN / UI ING AND SAFETY
Certified copy is hereby furnished. _ /
Certified copy is filed with tht•County building inspection
department. FOR APPLICANT TO FILL IN BUILDING Date Applicant (PRINT OR TYPE ONLY) ADDRESS 6 Primrose
CERTII'1CAiE OI'LXEIIPTION I'RU6i WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY Temple Celt
COMPENSATION INSURANCE NEAREST
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS S d
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. P BY V
1 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 r - ��
so as to become subject to the Workers' Compensation Laws. BOILER, BTU
APPROVALS DATE' INSPECTOR'S SIGNATTRE V
Date Applicant 1 COMPRESSOR,BTU 3—t_n ROUGH OW.
NOTICE TO APPLICANT: If, after malting this Certificate of VENTILATION SYSTEM FINAL 274 r Z
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
EVAPORATIVE COOLER VQ IDATM
with comply with such provisions or this permit shall be `f, --
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU tc%% iCtS^i ��
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-=-51_ Lic.Class C20
Contractor Date_812-2-40—
F1
82-2 40F1 I am exempt 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-
iness and Professions Code). PERMIT ISSUING FEE $ 7 AQ
Lic.or Reg.No. Date TOTAL FEE 17 0a
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
), 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).
❑ OWNER Frank Turiace
1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL
(Section 7044,Business and Professions Code). ADDRESS 6393 Primraqp ` 1 7 2 '1
CONSTRUCTION LENDING AGENCY CITY TEL.NOOQ7�'�Q� �f u o a a !I 1
I hereby affirm that there is a construction lending agency
for the performance of the %%ork for which this permit is CONTRACTOR
p p RKXKXKX Bryant Htg.
Z ° u � i,0 C'
issued(Sec.3097,Civ.C.).
Lender's Name ADDRESS
135_0 E. Las Tunas Dr. 0 C G 1 7.CU25
Lender's Address _ CITY San Gabriel TEL.NO286-1141
1 certifythat I have read this application and state that the 5 r
t pl STATE LIC. l '
above information is correct. I agree to comply with all County LICENSE NO. 22175 CLASS C2
orW�sState law, regulating Heating. Ventilating and
Areby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
Cnthe above-mentioned p ,pert for
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