HomeMy Public PortalAbout4510 TEMPLE CITY BLVD_Mechanical__ WORKLRS COMPENSATION UI CLARATION 76A3&4C '
1 hereby affirm that 1 haYL a tLrtifitate of cc' to Self CE 8161(280) APPLICATION FOR PERMIT _
insure or a certificate
reof( Workers Compensation Insurance or HEATING-VENTILATING-AIR CONDITIONING
u ternfYed copy thereof(Sec 3800 Lab C) LLL...III
Policy No Company
Certified Copy Is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy u filed with th Iy building inspection
y[X Ce ti ted, ,t FOR APPLICANT TO FILL IN BUILDING
UaLL Apphwnt / c (PRINT OR TYPE ONLY) ADDRESS 4510 Temple City Bld
CLRTII KATE Of LX 1 9T I HOM wOR KL HS
NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY Temple City
COMPENSA i ION INSURANCE NEAREST
(This Settlors need not he completed if the work InvolvedABSORPTION UNIT BTU CROSS ST d
by the permit u for one hundred dollars ($100) Or Iess)- DISTRICT NO PRO C BY Q
1 Lcrtify that in Ih,, performance of the work for which this AIR HANDLING UNIT CFM L)
permit is issued i shall not Lmplos any person in any manner p Cr
so is to become subject to thL Workers Compensation laws- BOILER BTU Q
APPROVALS DATE INSPECTOR SSIGNATURE UC
Data ADphcant COMPRESSOR BTU— f� ROUGH W
NOTICL TO APPLICANT If after making tilts CertifICAL of VENTILATION SYSTEM Z
LxLmpImn you should become subject to the Workers FINAL
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER
with comply with such provisions or this permit shall he
provisions _ VALIDATION
deemed revokLd FURNACE FAU -GRAVITY
LICENSED CONTRACTORS DLCl AR ATION FLOOR BTV
1 hereby affirm that 1 am licensed under provisions of Chapter HEATER SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Bust WALL
ness and Professions Code and my IltenSC IS In full force and /
effect �QQ r�fy
License Numb, /G�(//�J tJ/'��-� LIC Class�wx0
Contractor _ ``S Date / J -
❑ I a exempt from the licensing requirements as I am a
hcuacd architect or a rLgtsrered prOfeSSl01131 Lngmeer Plan check fee 25%of above
acting In my professional L.paeay (Section 7051 Bus
mess and Professions Code) PERMIT ISSUING FEE $
Lic or Reg No Date TOTAL FEE — aft'00V
HOML OWNER BUILDER DECLARATION PLAN CHECK APPLICANT ,pe
1 hereby affirm that i am exempt from the Contractors NAME County Heating 6 Air Cond. Inc.
License law for the following reason (Section 7031 5 Bust -
nese and Professions Code) - ADDRE-7515 S. Sunkist St. Suite A
1 as owner of the property will do the❑ work and the struLturL a not intended or uffLred for sale (&Lenon CITY Anaheim, CA 92806 TEL NO 937-5300 ;9021
021 4 A
7044 Business and Professions CoeL)
property am ex<Iusrvelycontracting OWNER HQHome Foodsde IIIc. 8
I as owner of the
with licensed contractors to construct the project MAIL 2r• • 3 Q'5 0
(Section 7044 Business and Prohtsions Code) ADDRESS 960B_LoWer_Azusn R a '
CONSTRUCTION LLNUING AGENCY CITY Temple City TEL N0213-443-9328 �•••�•:30.1505
1 hereby affirm that there is a u OSUL1 non lending agency
for the performance of the work for which this permit is CONTRACTORCount Heating 6 Air Cond. In 03.04 -83
issued (Sec 3097 Civ C )
Lender s Name ADDRESS -
JfjJ5 q quit
Lenders Address CITY Anaheim TEL NO 937-5300
1 certify that I base read this apphcaoOn and state that the STATE ILIC
abase Information is correct 1 agree to comply with all County LICENSE NO 32fi5fig CLASS C—
ordinances and State laws regulating HLatmf; Ventilating and
Air Conditioning and hertb) authorise reprLscniatises of this SLE REV ERSL FOR EXPLANATORY LANGUAGE
County to enter f%/ion the aa�b"ave mennunLd properiy for _
inapt ion )arpn '"
dnatun of Per utlLe ���