HomeMy Public PortalAbout9810 RICHMOND WAY_Mechanical__ WORKERS'COMPENSATION DECLARATION ®® AA
I hereby affirm that I have a certificate of consent to self �D��������®� ®1� PERMIT iY,�T
insure, or a certificate of Workers' Compensation Insurance, QQQ;�QQ�G • VENTILATING . AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C
Policy Nolo 1 Company STATE FUND 20_0046 DPW 9/88
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING 9810 RICHMOND
tion department. ADDRESS
(PRINT OR TYPE ONLY)
Date x'29-9� Applicant R. R01")ANIS LOCALITY TEMPLE CITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' c"Ross NEAREST LOWER AZUSA RD.
COMPENSATION INSURANCE
ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
(This section need not be completed if flee work involved by
the permit Is for one hundred dollars($100)or less.) 0 Q' _
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM , e
permit is issued, I shall not employ any person in any manner BOILER, BTU
so as to become subject to the Workers'Compensation Laws. l� APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant 1- COMPRESSOR, BTU `'I'8 0 000 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 VA ID I
with comply with such provisions or this permit shall be deem-
ed revoked. FURNACE: FAUAWITX 0�—
LICENSED CONTRACTORS DECLARATION 1 FLOOR BTU,/ 7�lJJ
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.
(.� CL
License Number 519622 Uc. Class C'20 ® U
ContractoR&F H:ETG/AIR Date 1O/31/9i O
❑ I am exempt under Sec. U
Plan check fee eu
B.BP.C. for this reason PERMIT ISSUING FEE $ o.
Signature Date:
Z
TOTAL FEE
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): j'
❑ 1, as owner of the property, or my employees with IADDRESS }q
s
A l C i .'B
wages as their sole compensation,will do the work and I CITY TEL. NO.
the structure is not intended or offered for sale(Section y,jl17 55.01)
7044, Business and Professions Code). OWNER
F1 1, as owner of the property, am exclusively contracting PTESTCO LAND CO. i"� ;
with licensed contractors to construct the project (Sec- MAIL -
;I 0 W. LAS TUNAS DR. -
tion 7044, Business and Professions Code). ADDRESS .I I.AL ._s=
5 mIj 0
CONSTRUCTION LENDING AGENCY CITY E yQiTy TEL. NO. CHECK j��,[f
1 hereby affirm that there is a construction lending agency for
286-3636
the performance of the work for which this permit is issuedCONTRACTOR R&F HTG & ATR COND. CHAt`ti-E .110
(Sec. 3097, Civ. C.).
ADDRESS 1 OAF—B INDUSTRIAL PARD
Lender's Name 010f_I[J_i 001 1(1/23/19---,
CITY COVINA TEL. N0.966-0011
Lender's Address Ar1 : =
1 certifythat I have read this application and state that the STATE 19622 LIC. C-20 = � rift (1�-�'
PP LICENSE NO. � � CLASS
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 for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
2gAd e.
Signature of Applicant or Agent Date li