HomeMy Public PortalAbout9810 WINDSOR LN_Mechanical__ DEC
WORKERS'COMPENSATION cafe of ons 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-certifieN coy thereof(Sec. 3800, Lab. C.) 76A364C
Policy No. �'0 �159Company STATE FUND 20-0046 DPW 9/88
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
s�jX Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
�I tion department. ADDRESS 8 r
-Applicant
Date
3-29-99R• R06'IA1VD (PRINT OR TYPE ONLY) "
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY TERIPLE CITY
CERTIFICATE OF EXEMPTION FROM COMPENSATION INSURANCE ORKERS' CROSSNEAREST. L01,'1ER AZUSA RD
(This section need not be completed If the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED.BBYY
the permitfor one hundred dollars or less.) p e
I certify thatt work
in the performance of the work for which this AIR HANDLING UNIT,CFM a
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU �� APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant COMPRESSOR, BTU `'i 8•000 ��— ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL ';L-12-71
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: FAUXGR VIN
LICENSED CONTRACTORS DECLARATION FLOOR FLOOR BTU_
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3.of the Business WALL.
and Professions Code,and my I icense is in ful I force and effect. ow �P `p
License Number 519622 Lic. Class C-20 /O CL
u
Contractor R&F HTG&AIR Date 10-31-91 W
❑ I am exempt under Sec. O
Plan check fee u
B.BP.C. for this reason a
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 my employees with ADDRESS
wages as their sole compensation,will do the work and CITY TEL. NO. ACC .F
the structure is not intended or offered for sale(Section �� ��
7044, Business and Professions Code). OWNER 330 55.0((
F-1 1, LAND CO.I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL O O 1 iITEMS''
tion 7044, Business and Professions Code). ADDRESS 9088 W. LAS TUNAS DR. TOTAL 55. 00
CONSTRUCTION LENDING AGENCY _
CITY
TL,pPLE CITY TEL. N0.286— 6 6 CHECK �d
I hereby affirm that there is a construction lending agency for �I:=•� _�_s.l�lJ
the performance of the work for which this permit is issued CONTRACTOR r 91 , CHANGE
,ilei
(Sec. 3097, Civ. C.).
Lender's Name
i ADDRESS 15o4-B INDUSTRIAL PARK
Lender's Address
CITY COVINA TEL. NO. 66-0011 (_ll�l]I]—!�lO�
� ..,.
1 certifythat I have read this application and state that the I STATE LIC. yjrf ' hj;[Io `
PP LICENSE NO. CLASS
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 a abov mentioned property r inspection purposes. I SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date @