HomeMy Public PortalAbout9802 WINDSOR LN_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, HEAPING - VENTILATING - AIR CONDITIONING
or a c&tified copy thereof (Sec. 3800, Lab. C.) 76A364C
104 1 9 STATE FUND 20-0046 DPW 9/88
Policy No. co 5 Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS 802 ' INDSOR LAVE
2 R. ROWAND (PRINT OR TYPE ONLY) LOCALITY r.
Date 3– 9-9�ApplicanT TI,'iViPLL: CITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. LOT17ER AZUS A RD.
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
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the permit is for one hundred dollars($100)or less.) C=MG
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM d
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU 1� APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant ] COMPRESSOR, BTU `'t'8 r 000 /.;L— 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 VALIDATION
with comply with such provisions or this permit shall be deem-
ed revoked. FURNACE: FAUXXAV
LICENSED CONTRACTORS DECLARATION 1 FLOOR BTU
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. 3 L— (� O
License Number 519 22 LLl
ic. Class C-20 , O
U
Contractor R&F HTG&AIR Date 10—, =91
❑ 0
I am exempt under Sec. FO
Plan check feePIMP— — u
LU
B.&P.C. for this reason N
Date: PERMIT ISSUING FEE $ Z
Signature TOTAL FEE
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):
❑ I, as owner of the property, or m employees with ADDRESS
P P Y� YAC-CT as their sole compensation,will do the work and AC-C 'a'
the structure is not intended or offered for sale(Section CITY TEL. NO. ;,
7044, Business and Professions Code). ='307 t•U.)�IJ
❑ OWNER C 'STCO LAND CO.
I, as owner of the property, am exclusively contracting e iTEMv
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS 9088 U LAS TUINAS DR. TCI AL 55-00
CONSTRUCTION LENDING AGENCY CITY TEL. NO. �� L-
I hereby affirm that there is a construction lending agency for F'AT TF CHECK 55.i_i
the performance of the work for which this permit is issued CONTRACTORR&F HTG & AIR GOND. i"HANGE .1111
(Sec. 3097, Civ. C.).
ADDRESS 1504—B INDI fSTRIAL PAPJC
Lenders Name
CITY COVINA TEL. NO.966-0011 tl000–;jl 011 10/235190
Lender's Address –
I certifythat I have read this application and state that the STATE LIC. =460 1 AV.1!4TI
PP LICENSE NO. 519622 CLASS C-20
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 the4ove--tinned prope y for inspection purposes.� SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Applicant or Agent Date