HomeMy Public PortalAbout9801 RICHMOND WAY_Mechanical__ WORKERS'COMPENSATION DECLARATION I APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self I
insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C.) 76A364C
101•!• 1 STATE MIND 2010046 DPW 9/88
Policy No.�QCompany� •
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec- + FOR APPLICANT TO FILL IN BUILDING p
tion department. I (PRINT OR TYPE ONLY) ADDRESS 9801 RICH14011D TNAY
Dat XP•3 29-.aIicantR. ROWAND ,NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY TEMPLE CITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST�,O{NER AZUSA RD. .
(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.)
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM ��
permit is issued, I shall not employ,any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU 'APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicarit COMPRESSOR, BTU 48■000 ROUGH
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 ALIDATION
with comply with such provisions or this permit shall be deem-
ed revoked. 1 FURNACE: FAU X GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
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. T_A1 4-0( eis �p
l CL
DD �
License Number 519622 Lic. Class C-20 , O
ContractorR&F HTG./AIR Date 10/31/91 I o
❑ I am exempt under Sec. I U
Plan check fee LU
B.BP.C. for this reason CL
PERMIT ISSUING FEE $ 3 — Z
Date: ?
Signature ' TOTAL FEE .�
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
1 hereby affirm that I am exempt from the Contractor's License ►
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS r s
wages as their sole compensation,will do the work and ACCT■F
the structure is not intended or offered for sale(Section CITY TEL. NO. 5I1
7044, Business and Professions Code). 3311317 .
OWNER WESTCO LAND CO t:
❑ I, as owner of the property, am exclusively contracting � �T��'1,,�
with licensed contractors to construct the project (Sec- MAIL O D
tion 7044, Business and Professions Code). ADDRESS 088 VI]° LAS TU 1 OTAL 55-00
CONSTRUCTION LENDING AGENCYCITY TEL. NO.
I hereby affirm that there is a construction lending agency for ! TEMPL 286- [ ■O`i
the performance of the work for which this permit is issuedCONTRACTOR COND. 01111. CHANGE ,lIj
(Sec. 3097, Civ. C.).
ADDRESS 1504—B INDUSTRIAL PARK
Lender's Name I y _
CITY COVINA TEL.NO.$ 8= m 1100-001 �O�iJ/4'j,l
Lender's Address
I certifythat I have read this application and state that the STATE LIC. s M ■ 4
pP LICENSE NO. 519622 CLASS C-20
��tt_$ It10■fir,
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
upon the above-mentioned property f r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
,>r,im
Signature of Applicant or Agent r Date