HomeMy Public PortalAbout4333TEMPLE CITY BLVD_Mechanical (2) DEC
TION
WORKERS'affirm
that
have COMPENSATION cafe of corse APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
-n
insure, ora certificate Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof
16A364Cof (Sec. 3800, lab. C.)
-yY 20-0046 DPW 9/55
Policy Cert
- y ified copy is hereby furnished.reempanCOUNTY OF LOS ANGELES BUILDING AND SAFETY
--
❑ Certified copy is filed with the county building Inspee FOR APPLICANT TO FILL IN BUILDING
tion department. (pi OR TYPE ONLY) ADDRESS 'f
Data - Applicant LOCALITY :;1 I �
No. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved by AB50RPTION UNIT, OTU DISTRICT NO. PRoersSED 9y
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 IF
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 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- - q
ed revoked. - FURNACE: FAUGRAVITY t -C .
LICENSED CONTRACTORS DECLARATION FLOOR BTU
- 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
J
and Professions Code,and my license is in full force and effect. t- J - .•� a s '. >
iIt
i
License Number Lia Class O
W
Contractor Dore ' W
❑ 1 am exempt under Sec
Plan check feet R m
B.BP.C. for this reason v
PERMIT ISSUING FEE 5 .p•,I -
Date: O
TOTAL FEE
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License pC
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.
the structure is not intended or offered for sale(Section
OW
7044, Business and Professions Code). > " r
NER �+�,� // r•s�,
F-1I, as owner of the property, am exclusively contracting �
1,with licensed contractors to construct the project (Sec- MAIL -14—
tion 7044, Business and Professions Code). ADDRESS Itl' 2E " U)
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. 3097, Civ. C.).
ADDRESS
Lender's Nama
cCITYa TEL. No. r 15.1 !.
Lender's Address r - S
I certifythat I have read this application and state that the STATE CLLIC _' -
Pe LICENSE NO. CLASS -
above information is correct. agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter f x.
upon the above-mentioned property for inspection purposes +q'�,d c x.r ' rll L s� •ap Y
SEE REVERSE FOR EXPLANATORY LANGUAGE 4s }} ; der •1 ` '`,1
Signoture of Applicant or Agent Date u s` I E�.h✓ ,� ®s!
at ''
r1; 6'? `,• '.� ,. dtlt i - t•?' M..�QS 'x'S ''
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