HomeMy Public PortalAbout9813 WINDSOR LN_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
ivisure, or.a certificate of Workers' Compensation Insurance, HEAPING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C
1047159 STAT ; FUi4D 20'0046 DPW 9/88
Policy No. Company Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Jigk Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS 9813 JISDIS OR LANE
Date -3-29-90 Applicant Re .LRQIIAIJA� LOCALITY TL.?PLL CITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE
C
COMPENSATION INSURANCE ORKERS' CROSSNEAREST. LO12R AZUSA RD.
(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.)
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM
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
1 COMPRESSOR, BTU 48 s 000 � � ROUGH
Date Applicant
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 XX
BTU RA U�—
LICENSED CONTRACTORS DECLARATION FLOOR lJ
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. / L e i
License Number 519622 Lic. Class C-20 , 0
O
U
Contractor R&F HTCT&AIR Date 10-331-91 O
❑ I am exempt under Sec. 11�_
Plan check feeZ Aa- - U
B.BP.C. for this reason H
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):
ADDRESS
I, as owner of the property, or my employees with
F1 `� a
wages as their sole compensation,will do the work and '= (�v
the structure is not intended or offered for sale(Section CITY TEL. NO. psi l� •-
7044, Business and Professions Code). OWNER 55. ,C
.SSTC O LAND C O o , z,.,_
❑ I, as owner of the property, am exclusively contracting MAIL 1
with licensed contractors to construct the project (Sec- ADDRESS 9088 J. LAS TUiJ4S DR. i IiTAL 55. 00
tion 7044, Business and Professions Code). j
CONSTRUCTION LENDING AGENCY CITY ,, a r, TEL. N0-286-3636
T.,__PL.1 CITY NECK 55 ;
I hereby affirm that there is a construction lending agency for U-'o I i1=
the performance of the work for which this permit is issued CONTRACTOR -FHTGAIrjIq
, ti.y-�j"yhji�E
(Sec. 3097, Civ.C.).
ADDRESS1504—B INDUSTRIAL PARK
Lenders Name i
CITY COVINA TELNO. 66-0011 - 1-j1.''I_I11i il_Uf ��ili
Lender's Address
I certify that I have read this application and state that the LICENSE NO. 1 622 CLASS C-20ATE LIC. '461 1 FM,IZ. 4.'
above information is correct. I agree to comply with all County li
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon the above-mentioned proper for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date