HomeMy Public PortalAbout9807 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, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) 76A364t
Policy No.
l047159 Company STATE FUND 200046 DPW9/88
COUNTY OF LOS ANGELES BUILDING AND SAFETY
F1 Certified copy is hereby furnished.
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDINC807 RICHMOND WAY
tion department. (PRINT OR TYPE ONLY) ADDRESS
Dat %XP.3-29-94plicant R.ROWAND LOCALITY TEMPLE CITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST LOWER AZUSA RD
COMPENSATION INSURANCE CROSS ST.
(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.) AIR HANDLING UNITCFM �
I certify that in the performance of the work for which this -, " 0
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
�- COMPRESSOR, BTU 489000 ROUGH
Date Applicant
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 VAL A O
with comply with such provisions or this permit sho
ll be deem-
ed revoked. 1 J
FURNACE: FAU 7QA '12FLOOR ,r
LICENSED CONTRACTORS DECLARATION vw _ Al
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.
License Number519622 Lic. Class(1-20 , O
U
ContractoR&F HTG/AIR Date 10131/91 oe
❑ I am exempt under Sec. V
Plan check fee
B.&P.C. for this reason PERMIT ISSUING FEE $ — an
d
Date: Z
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
❑
wages as their sole.compensation,will do the work and CITY TEL.NO. a _
the structure is not intended or offered for sole(Section
7044, Business and Professions Code). OWNER-WESTCO LAND CO. 3307 55.00
❑ I,as owner of the property, am exclusively contracting n 1 ITEMS
ADDRESS9
with licensed contractors to construct the project (Sec- O$8 W. LAS TUNAS DR.
tion 7044, Business and Professions Code). TOTAL 55 .00
CONSTRUCTION LENDING AGENCY CITY 'TEMPLE CITY TEL.NO-286-3636 CHECK . �
I hereby affirm that there is a construction lending agency for t t ('l�
the performance of the work for which this permit is issued CONTRACTORATg GHAh�E .OLI
(Sec. 3097, Civ. C.). ADDRESS 1504—B INDUSTRIAL PARK
Lenders Name
CITY TEL. NO. 1]131113-0001 10/23/90
Lenders Address COVINA 966-0011 TATE LIC. _
44
I certify that I have read this application and state that the LIC NSE N 1 622 CLASS C--20 '� 1 '
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 above4:;;W
y for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
,lVT ienT& 0_2 2---?6
Signature of Applicant or Agent Date