HomeMy Public PortalAbout4333TEMPLE CITY BLVD_Mechanical TION
WORKERS'affirm
that
I have
a certificate
of once APPLICATION FOR PERMIT
I hereby affirm that haver certificate of consent to self rr {•(
insure, oracertificate e Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sac. 3800, Lab. C. 76A361C
:� -�-/ ` CE-818(REV. 10/81)
Policy No. - Company �� I �7/ �-r .
l��J•1 Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county build' Inapac- - - FOR APPLICANT TO FILL IN BuaDING
tion department. �y /g ADDRESS
/� (PRINT OR TYPE ONLY)
Date/.J '` 'i'r /r' �.CY `.l-. - LOCALITY .-.•r 41
t Applicant f' NO. TYPE OF APPLIANCE.OR EQUIPMENT FEE ` 1
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CRO55 57. Lr•. - -re
(This section need not be completed UNIT, BTU
ed If the work Involved by DISTRICT NO PRo<Esse�e-
the permit Is for one hundred dollars ($I00)or bas.)
-
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM r ..
permit is issued, I shall not employ any person in any manner BOILER, BTU
so as to become subject to the Workers'Compensation LOWS. APPROVALS DATE INSPECTOR'S SIGNATU E
Date Applicant COMPRESSOR, BTU ROUGH
F 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
deemed revoked. FURNACE: FAU_GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPENDED WALL - UNIT_
. _s >_
and
with Section 7000)of Division 3 of the Business a
and Professions Code and my license is in full force and effect. + O
License Number �r otic. Class , 0LL
7.
W
v, �4 LL
Contractor [" ' i. Date'
❑ 1 `3 L 1 7 ;; W
am exempt under Sec. Plan check fee a� ;` �4 h o r u
B.BP.C. for this reason
Date. PERMIT ISSUING FEES ' _ • •, t J r. a
f.'
SignatureTOTAL FEE Lu
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License - pop.Law for the following reason (Section 7031.5, Business and NAME �.�. / '��
Professions Code): '
y L
❑ I, as owner of the property, or my employees with ADDRESS ��-
wages as their sole compensation,will do the work and CITY TEL. NO. r!i/
the structure is not intended or offered for sole(Section - -
OWNER
7044, Business and Professions Code).
❑ �: �r w
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL . / -04 ,
tion 7044, Business and Professions Code). ADDRESS y
CONSTRUCTION LENDING AGENCY CITY TEL. No.
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3197, Civ. C.).
' Lender's Name ADDRESS
CITY TEL NO.
Lender's Address
I certifythat I have read this application and state that the STATE _ LIC.
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 the above-me oned.proper)y.far inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent _ Dote