HomeMy Public PortalAbout5526 TEMPLE CITY BLVD_Mechanical__ WORKLRS COMP)NSATION DECLARATION 78A384C APPLICATION FOR PERMIT
CE 8181280)
I hereby affirm that I have a certificate of consent to self
insure or a certificate of Workers Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec 3800, Lob C )
Policy NMT81139,8D#aa) Fremont Tntdpmn7 t y
❑ CLrtlfled copy Is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
® Certified copy tsfiled:vith the county budding msp,ctson FOR APPLICANT TO FILL IN BUILDING
department r� ADDRESS 5526 Temple Cit Blv
Dole Applicant Bryant HC(_• (PRINT OR TYPE ONLY) City
ICATE Or EXEMPTION PROM WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY Temple City
COMPENSATION INSURANCE - NEAREST T
(This sectton need not be completed rf the work Involved ABSORPTION UNIT BTU CROSS ST CL
bythe permrt Is for one hundred dolltus (SI00) or less) DISTRICT rio PROCESSF^ 8
1 certify that In the performance of the work for which this AIR HANDLING UNIT CFM y/
permit IS Issued 1 shall not employ any person in any manner
so as to become subject to the Worklra Compensation Laws BOILER BTU
APPROVALS DATE %,.a�014 S SIGs RE
Date Applicant 1 COMP'RESSOR BTU--U0 a
ROUGH t/1
NOTICE TO APPLICANT If after making this Certificate ofVENTILATION SYSTEM FINAL 2
LxLmptlon jou should become subject to the Workers
Compcnsetson provisions of the Labor Code you must forth EVAPORATIVE COOLER
with comply „nth such provisions or this permit shall be VALIDATION _
deemed revoked 1 FLOOR
FAUX G �Tj�—
LI(.LNSLD CONTRACTORS DLCLAR ATION "'"'— 20 OC
1 hereb, affirm that I am hcensed'under provisions of Chapter HEATER SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Buss WALL
ness and Professions Code and my license ss in full force and '
effect
License `'
Number21751 Lie Class C-20
ContZrryant Htg. Date t
❑ I am exempt from the licensing requirements as I am a
hcenscd architect or a registered professional eng nccr Plan check fee 25% Of above
acting in my professional capacity (Section 7051 Bus
mess and Professions Code) PERMIT ISSUING FEE $4370�)-Lie or Reg No Date TOTAL FEES
HOME OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's NAME
I reense Law for the following reason (Section 7031 5 Buss `
tress and Professions Code) ADDRESS -4:1594A
❑ I as owner of the property .,it do the work and the '
structure is not intended or offered for sale (Section CITY TEL NO # • •'. • 8
7044 Business and Professions Code) ,
❑ OWNER Tom Schaub 2;•)• 3,700
I as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL 0 - 37005
(Section 7044 Business and Professions Code) ADDRESS 526—Temple City—Bl-v& '
CONSTRUCTION LLNDING AGENCY CITY TEL NO I 0. 1j9-81
1 hereby affirm [hat there IS a construction lending agency _ Temple—City _ 286-3483
for the perforrI of the work for which this permit is CONTRACTOR
Issued (Sce 3097 Civ C) Bryatdc Heat--&—A—C.
Lenders Name _ ADDRESS 1350 E. Las Tunas Dr
Lender s Address
CITY San Gabriel TEL No 286-11 L
I certify that I have read this apphcstsun and state that the STATE221751 LIC
d bo� formation iscorrect I agree to comply with all Cuunry I ENSE NO CLASS C20
r na ccs and Sta(, laws regulating Heating Ventilating and
r o nddlonmg and hereby authonte repres,ntabses of this SEE REV LRSE I OR EXPLANATORY LANGUAGE
tui v to enter upon 9V above mentson,d property for
' s ,, lion purps -
gnatu a of Poseermittee