HomeMy Public PortalAbout9816 WINDSOR LN_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I herr-by affirm that I have a certificate of consent to self
irlyure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C
Polis No. FUND 2D-0046 DPW 9/88
F-1Certified
10 �-S�.CompanySTAT��
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Pq Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING816 :7I1VllSJR LAID
Date 7 Applicant
tion deRartm nt. �T ADDRESS9816
3-27-9� R e R�I.rAND r (PRINT OR TYPE ONLY)k
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY TE;iPL.3 CITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. LO vP2R AZU:SA RD-
(This
De(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. I BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant
COMPRESSOR, BTU 48}000 ,P— -- ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL /L
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 VI
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.
v }
License Number 519622Lic. Class C-20 , O
ContractorR&F HTG&AIR Date 10-31-91 0
❑ I am exempt under Sec. — U
Plan check fee W
B.&P.C, for this reason. d
PERMIT ISSUING FEE $ 1.� — Z
Date:
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
r n^•- t
wages as their sole compensation,will do the work and °4
CITY TEL. NO.
the structure is not intended or offered for sale(Section
7044, Business and Professions Code).
❑ OWNER
1, as owner of the property, am exclusively contracting iTESoT CO LAND CO.
with licensed contractors to construct the project (Sec- AMAIL DDRESS 9088 'T. LAS TUNAS DR. I A� �p
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY '" A + TEL. NO. �' r r' 00
�°Y,
TE:�I�LL CTiTY 286-3 3 ti•I EDCK
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR R&F HTG & AIR COND. CHANE
(Sec. 3097,3097, Civ. C.).
ADDRESS 1504—B INDUSTRIAL :PARK
Lender's Name
CITY COVINA TEL. NO. 966-0011
Lender's Address
I certifythat I have read this application and state that the STATE LIC. �`tU i Ei��Lio'tl:
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 Qf this County to enter
upon the above-mentioned property ft
inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date @