HomeMy Public PortalAbout9816 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.) 76A364C
PolicyNo.
104 l 9Company 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 9816 RICHI,IOND WAY
tion department. ADDRESS
(PRINT OR TYPE ONLY)
Date—l--29-94Applicant R. ROWAND LOCALITY TEI-JPLE CITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST. LUATER AZUSA RD.
COMPENSATION INSURANCE
(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 BOILER, BTU O /
so as to become subject to the Workers'Compensation Laws. 48.000 APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant �- COMPRESSOR, BTU f 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
with comply with such provisions or this permit shall be deem-
ed revoked. FURNACE: FAU X
LICENSED CONTRACTORS DECLARATION �- FLOOR aTll 1 7.UUU
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. c / }
License Number 519622 Lic. Class C-2o ll , U
Contractor Date HTG & AIR Date 10-31-91
❑ I am exempt under Sec. U
Plan check fee � W
B.&P.C. for this reasona
PERMIT ISSUING FEE $ �' —
Date: Z
Signature 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):
❑ I, as owner of the property, or my employees with ADDRESS r1r 4"C a
wages as their sole compensation,will do the work and ' °Q
CITY TEL. NO.
the structure is not intended or offered for sale(Section �;-� :=c
7044, Business and Professions Code). VES "u(.t� "stil°Iii'
❑ OWNER ITCO LAMCO. ITE11S
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS 9088 W. LAS TUNAS DR. TOTAL 55 m 030
CONSTRUCTION LENDING AGENCY CITY � TEL. NO. t: ^[f 55.C-143 I hereby affirm that there is a construction lending agency for TEIVIPL� CITY 286— 6 6 �_.ti
the performance of the work for which this permit is issued CONTRACTOR R&F HTG & AIR C ONDITI ONINC 01111. CHANGE
(Sec. 3097, Civ. C.).
ADDRESS 1504—B INDUSTRIAL PARK
Lender's Name 0000-0001 10123`910
CITY COVINA TEL. N0,966--001 .
Lender's Address STATE LIC. 3471 1il__1 f I o�
1 certify that I have read this application and state that the LICENSE NO. 519622 CLASS C-20
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 prope,ry for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date