HomeMy Public PortalAbout9623 VAL ST_Mechanical__ '` WORKEDs�'COMPENSATION DECLARATION
hereby,affirm fiat I have a certificate of consent to self APPLICATION FOR PERMIT
ornate ored copy f (Sec 3800 Lab C )certificate of Workers' Compensation Insurance
or o certified thereo7&k364C HEATING - VENTILATING - AIR CONDITIONING
r CE SIS(REV 10/81)
Policy No Company
I}L�npJ{ Garotted copy is hereby*thnty
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed wuil inspec- FOR APPLICANT TO FILL IN BUILDING
hon deportment (PRINT OR TYPE ONLY) ADDRESS 9623 VaI Street
��Appl ice OCALITYNO TYPE OF APPLIANCE OR EOUIPMENi FEECERTIFICATE OF SATIORKERS' NEAREST
COMPENSATION INSURANCE CROSS Si C
(This section Med not be Completed R the work Involved by ABSORPTION UNIT BTU DISTRICT rR0 PRDCESSED BY
the permit Is for one hundred dollars($100)or less ) AIR HANDLING UNIT CFM ��`` /f 7!I/
I certify that in the performance of the work for which this '51 v U
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers Compensation Laws BOILER Bit APPROVALS DATE w T S SIGNATURE
Date Applicant COMPRESSOR BTU 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 VALIDA O
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU_GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 1 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 \ LI d d
License Number Class
oil.
V
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Contrac'a e—i-1�'i--��- O
I am exempt under 5 Vto
Plan check fee - N
B 8P C for this reason PERMIT ISSUING FEE $ s Z
Dote 'j 7 �,
Signature TOTAL FEE #
I • •3 Q 5 0
OWNER BUILDER DECLARATION RAN CHECK APPLICANT • • 03050 6
I hereby off irm that I am exempt from the Contractor s License ,
Low for the following reason (Section 7031 5 Business and NAME a 2 —85
Professions Code) 0
❑ I as owner of the property or my employees with ADDRESS '
wages as their sole compensation will do the work and CITY TEL NO
the structure Is not intended or offered for sale(Section
7044 Business and Professions Code) �F j
OWNER John SteenHa--'�
EJI as owner of the property am exclusively contracting
with licensed contractors to construct the project (Sec MAIL
RE55 9623 Val Street
hon 7044 Business and Professions Code)
ADDCONSTRUCTION LENDING AGENCYary Temple Ci TEL NO 446-0089
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR T A Russell C Cti C �i
(Sec 3097 Civ C )
Lender s Name ADDRESS 222 W Foothill Blvd L
Lenders Address ' CITY Glendora 'EI NO 331-3157
STATE I coni have read this application and stale that the LICENSE NO 353614 CCI SS B
ab formate is correct I agree to comply with all County
or es and tat s relating to budding construction
out Iz resentatives of this County to enter
bo property for inspection urposes; SEE REVERSE FOR EXPLANATORY LANGUAGE
Slgnnrore of Appliconi or Agent Date