HomeMy Public PortalAbout5936-5936 1/2 TEMPLE CITY BLVD_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C APPLICATION� FOR
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I hereby affirm that I have a'ceriificaik of consent to self CE-818 (2-80) Ir ®If t; tl�ll 0�
insure, or a certificate of Workers'Compensation Insurance,Or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. 231079QQ y Ca. Casua 1 ty _
I ndemn i ty
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES f BUILDING ARID SAFETY
® Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
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LTnt• ADDREss5936— Temple Cit Blvd
Date g� Applicant E. L. PAYNE OMANI Y (PRINT OR TYPE ONLY)
LOCALITY — -Weot#ra ;�l'em
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST d
(This section need not be completed if the work involved ABSORPTION UNIT,BTU cRoss ST. Woodruff 0
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESS BYE C)
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM CC
permit is issued, I shall not employ any person in any manner S� O
so as to become subject to the Workers'Compensation Laws. BOILER,BTU
APPROVALS DATE I INSPECTOR'S SIGNATURE W
Date Applicant E_ L. PAYNE COMPANY 1 COMPRESSOR,BTU ROUGH �
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM S F z
Exemption, you should become subject to the Workers' FINAL —
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU= GRAVITY—
LICENSED
RAVITY LICENSED CONTRACTORS DECLARATION I FLOOR: BTU (�
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in.full force and
effect.
License Number 190228 Lic.Class C-20
Contractor E. L. PAYNE Date 6-8-81
❑ I am exempt from the licensing requirements as I an a e
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$ ] 00 .
Lic.or Reg.No. Date I TOTAL FEE 27 100
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
1 hereby affirm that I am exempt from-the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS
❑ I, as owner of the property, will do the work and the CITY TEL. NO.
structure is not intended or offered for sale (Section 20 1 9.8 A
7044,Business and Professions❑ Cod r). OWNER
I, as owner of the property, am exclusively contractingi+',' 0 0 0 o U 1
with licensed contractors to construct the project MAIL
(Section 7044,Business and Professions Code). ADDRESS 2 0 - 27.00
% CITY i TEL.NO. 6�„��
CONSTRUCTION LENDING AGENCY o o'o 2 7 0 0.0
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR.
issued Sec.3097,Civ.C.). 0615-81
Lenders Name ADDRESS
Lender's Addressr
CITY TEL.NO.
I certify that I have read this application and state that,the STATE LIC.
above information is correct.I agree to comply with all County LICENSE NO � CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County enter upona above-mentioned property for
ins c purposes.
ature of Permit,*e Date