HomeMy Public PortalAbout9802 RICHMOND WAY_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, I��AgIh�G . VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C
1047159 company STATE FUND 20-0046 DPW 9/88
Policy No. p y
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building in pec- FOR APPLICANT TO FILL INBUILDING
tion department. ADDRESS 9802 RICHMOND WAY
yXP e�- r' (PRINT OR TYPE ONLY) LOCALITY r
Date y °Z2-JI1Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CEIVMLE CITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. LOWER AZUSA
(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 as
permit is issued, I shall not employ any person in any manner BOILER, BTU
so as to become subject to the Workers'Compensation Laws. APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant 1 COMPRESSOR, BTU 480000 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 VALID 10
with comply with such provisions or this permit shall be deem-
ed revoked. FURNACE: FAU
LICENSED CONTRACTORS DECLARATION 1 FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT—
(commencing with Secfion 7000)of Division 3 of the Business I I WALL.
and Professions Code,and my license is in full force and effect. -
License Number 519622Lic. Class C-20 ® d
O
Contractor R&F HTG/AI ate l0/31/91 0
❑ - I am exempt under Sec. V
Plan check fee � u,
B.&P.C. for this reason CL
PERMIT ISSUING FEE $ 1 j — Z
Date: _
TOTAL FEE
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I 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 P�f•_ a
wages as their sole compensation,will do the work andoa
the structure is not intended or offered for sale(Section CITY TEL. NO. L•ilfi 5:1.131 3
7044, Business and Professions Code).
❑ I, as owner of the property, am exclusively contracting OWNER' W-moo STCO LAN)) CO I ITEMES
MAIL
tion 7044, Business and Professions Code).
with licensed contractors to construct the project (Sec- ADDRESS 9088 V1 e LAS TUNAS DR. TOTAL HL _v m 0_0
CONSTRUCTION LENDING AGENCY CITY TEL.NO. 'CHECK 55. i ;
I hereby affirm that there is a construction lending agency for TEMPLE CITY 286— 6 6 �a
the performance of the work for which this permit is issued CONTRACTOR R&F HEATING & AIR COND ® t•I-If�i�L�E ,s:l.
(Sec. 3097, Civ. C.).
ADDRESS 1504—B INDUSTRIAL PARK
Lender's Name
CITY COVINA TEL. NO. 66-0011 ,
Lenders Address STATE LIC. , 7 ,.
I certify that I have read this application and state that the LICENSE NO. 2 CLASS '-r 141 y�`��I�'--r
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 bove-mentioned propert for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Dote G