HomeMy Public PortalAbout9821 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 o certified coy thereof (Sec. 3800, Lob. C.) 76A364C
104715990 STATE FUND 20.0046 DPW 9/88
Policy No. ompany
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
iCertified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING 9821 RICHMOND WAY
department. (PRINT OR TYPE ONLY) ADDRESS
2.9-90 Applicant R. ROWAND LOCALITY TEMPLE CITY
Date.., ' NO. TYPE OF APPLIANCE OR EQUIPMENT � FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. LOVER 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 Applicant �- COMPRESSOR, BTU 6)(7),non 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 VALI N
with comply with such provisions or this permit shall be deem-
ed revoked. FURNACE: FAU X GRAVITYM _
LICENSED CONTRACTORS DECLARATION 1 FLOOR B7u
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. /� S ' _ o� }
License Number 519622 CL
Lic.class Cm20 Cl O
Contractor R&F HTG & AIpDote 10-31-91 , 0
❑ I am'exempt under Sec. .,, �
Plan check fee d
B.&P.C. for this reason PERMIT ISSUING FEE $
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):
El 1,
I, as owner of the property, or my employees with A(;CT°Q
wages as their sole compensation;.will do the work and CITY TEL.NO.
the structure is not intended or offered for sale(Section t ' 33307 57.00
1
7044, Business and'Professions Code). s
❑ I, as owner of the property, am exclusively contracting OWNER,TvVESTCO LAND COL 1 ITEMS
EMS
with licensed contractors to construct the project (Sec- MAIL 9088 W LAS TUNAS DR
tion 7044, Business and Professions Code)'. ADDRESS W. TOTAL SAL 57 m DID
CONSTRUCTION LENDING AGENCY CITY i TEMPLE CITY TEL. NO.286-3636 CHECK .5_;7,1;11
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRA CTORR&F HTG & AIR COND. CHANGE III
(Sec. 3097, Civ. C.).
ADDRESS _
Lender's Name CITY COVINA TEL.NO.966-0011 �' �'-III 1"s1 f( Ii3I l]
Lender's Address kt_t
I certify that I have read this application and state that the STATE
NO. 5.9622 CLASS 0®20
���� itftl°4ti
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 propeA for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Applicant or Agent Date