HomeMy Public PortalAbout9807 WINDSOR LN_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I ,herelay affirm that I have a certificate of consent to self
,insure, or a certificate ofi Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C.) 76A364C
STATE FUND 20-0046DPW 9/88
Policy No-1047159Company
F1 Certified copy is hereby furnished. - COUNTY OF LOS ANGELES BUILDING AND SAFETY
19 Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS 980 . WINDSOR LANE
Date 3-29-9 Applicant R. RO'NAND LOCALITY TE,1_'JIPLE- CITY.
• NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST LOWER A2USA RD.
COMPENSATION INSURANCE CROSS ST.
(This section need not be-completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
• the permit is for one hundred dollars(;100)or less.) a Q
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM V o
permit is issued, I shall not employ'any person in any manner BOILER, BTU
so as to become subject to the Workers'Compensation Laws. APPROVALS DATE INSPECrOR'S SIGNATURE
Date Applicant.
1 COMPRESSOR, BTU 48-(1100 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: FAU X G AV
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.
O d
License Number 519622 Lic. Class L'`20 ► O
Contractor R&F HTG&AIR Date 10-31=91 WO
❑ • I am exempt under Sec. V
Plan check fee — W
B.BP.C. for this reason PERMIT ISSUING FEE $ 3 d
Date: 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 -my employees with ADDRESS
wages as their sole compensation,will do the work ands
the structure is not intended or offered for sale(Section
CITY TEL. NO. �1 °�
7044, Business and Professions Code). `��'(]`�. ITEMS
55.03°55.03❑ OWNER 4VESTCO LAND CO.
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL 908$ W LAS TUNAS DR
tion 7044, Business and Professions Code). ADDRESS TOTAL 55. 00
CONSTRUCTION LENDING AGENCY CITY TEMPLE CITY TEL. NO-286-3636 CHECK, 55.0[1
I hereby affirm that there is a construction lending agency for _
the performance of the work for which this permit is issued CONTRACTOR CHANGE Il
(Sec. 3097, Civ. C.).
R&F HTG & AIR C OlVD. , HAiJE ° U
Lenders Name
ADDRESS 1504—B INDUSTRIAL PARK
+,•�
CITY Q TEL.NO. 0000-0001 10/23/90
Lenders Address '
1 certifythat I have read this application and state that the STATE LIC. 4' M t�T°r'
PP LICENSE NO. 519622 CLASS Cm20 A�#EO=-r
above information is correct. I agree to comply with alllCounty
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
u the ob ve-mentioned prope y for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date