HomeMy Public PortalAbout9822 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, HEATING - VENTILATING - AIR CONDITIONING
or a certified c�p thereof(Sec. 3800, Lab. C.) 76A364C
Policy No.1' 159 Company'STATE FUND 20-0046 DPW 9/88
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
® Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS 9822 WINDSOR LANE
DoteE')s•3-29-91pplicantR. ROWAND LOCALITY TEP I,
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
; CITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. 7
(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
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM Q
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. IBOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant
COMPRESSOR, BTU 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 3�_GRAVITY
LICENSED CONTRACTORS DECLARATION 1 FLOOR
I hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPENDED UNIT—
(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in ful I force and effect.
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-_ /�
47& ( CL}
License Number 519622 Lic. Class (-'— — , 0
O
ContractorUF HTG & AIRDatJO-31-91 u
�e
❑ I am exempt under Sec. V
Plan check fee W
B.BP.C. for this reason PERMIT ISSUING FEE $ j
�-
Date:
TOTAL FEE
Z
Signature
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 a
wages as their sole compensation,will do the work and AMA _
the structure is not intended or offered for sale(Section CITY TEL. NO. 3307 , f 'I :
7044, Business and Professions Code). _
❑ OWNER 'uTESTCO LAND CO. _ t.•;
I, as owner of the property, am exclusively contracting f �tf�•:
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS 9088 t,a>� sr. LAS TUNAS DR. 'fl_I),�t1 E ,
CONSTRUCTION LENDING AGENCY CITY TEL. NO. 6:1 (: 'r ,010
I hereby affirm that there is a construction lending agency for
TEMPLE CITY CA. 286— 6 6 HE K ` 1 i
the performance of the work for which this permit is issued CONTRACTOR R&F HTG & AIR COND. CHANGE °-i
(Sec. 3097, Civ. C.).
ADDRESS -IDITSTRIA , PARK '
Lender's Name
CITY COVINA TEL. NO. 966-0011
Lender's Address
STATE LIC
I certify that I have read this application and state that the LICENSE NO.519622 C ASS 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
authe Zabqve- entt d property •r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date