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Home My Public Portal About4516TEMPLE CITY BLVD_Mechanical (2) WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT `�er� affnm that 1 have o certificate of consent to self ure or d certificate of Workers Compensation Insurance ad copy thereof (Set 3800, Lab C 7 ,C - HEATING- --VENTILATING - AIR CONDITIONING or a cerhF ) 7&4364C7&4364C CE 818(REV 10/81) - Policy No Company Certified copy is hereby furnished COUNTY OF LOS ANGELES _ BUILDING AND SAFETY ' ❑ Certified copy is filed with the county building mspec ' FOR APPLICANT TO FILL IN BUILDING r c l� ' h (PRINT OR TYPE ONLY) on department ADDRESS (� £An Tin —, A r Date Applicant LOCALITY CERTIFICATECIF EXEMPTION FROM WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT FEE NEARESTn ` COMPENSATION INSURANCE CROSS ST OCAJ L US� (This section need not be COmplated If the NOrk Imwlred by ABSORPTION UNIT BTU - OISTRICI NO PROCESSED BY the permit Is for oee hundred dollars($100)or less) AIR HANDLING UNIT CFM -C- I certify that in the performance of the work for which this � permit a issed 1 shall not employ a rson In any manner ' so as to be Dm subject to the Wo am Compenyahon L BOILER BN APPROVALS DATE IN OR 5 SIGNATURE Dote / � PP]= COMPRESSOR BTU ROUGH NOT( T APPLICANT 'If, a or making th15�CerWkote of VENTILATION SYSTEM /r7� s'cl FlNAL /L Exemption you should bac a bject to the Workers Compensation provisions of the a or C. you must forth- EVAPORATIVE COOLER V LIDATION 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 9 SUSPENDED—UNIT— (commencing USPENDEDUNIT_(commencing with Section 7000) of Division 3 of the Business HEATER WALL and Professions Code and my license Is in full force and effect - - d License Number LIc ClassV Contractor Date ❑ I am exempt under Sec5 6 Plan check fee # d B 8P C for this reason ( 0 02050 W PERMIT ISSUING FEE $ Date �j�j ��rr o Signature TOTAL FEE 0 1 1 b 4 8 g OWNER BUILDER DECLARATION RAN CHECK APPLICANT k I hereby affirm that I am exempt from the Contractor s License Low for the following reason (Section 7031 5 Business and NAME Professions Code) D ❑ I as owner of the property or my employees with ADDRESS ��/�/� f% wages as their sole compensation,will do the work and �+ the structure Is not Intended or offered for sale(Section CITY / c�^ ` TEL NO �Q ras�6 7G44 Business and Professions Code) - ❑ I as owner of the property am exclusively contracting OWNER with licensed contractors to construct the project (Sec MAIL tion 7044 Business and Professions Code) ADDRESS CONSTRUCTION LENDING AGENCY CITY /9f/jJ L/Y A- TEL-NO 3 I hereby affirm that there is a construction lending agency for q e ► the performance of the work for which this permit Is Issued CONTRACTOR (Sec 3097 Cw C ) ADDRESS .fly uyarr'rC Lender s Name e� [,� 46 9- TEL NO Lender s Address CITY that I have read this application and state that the STATE pgQ0 LIC I certify PP LICENSE NO 'VV 66 CLASS above information is correct I agree to comply with all County aroma and State laws relating to budding construction and are authorize representatives of this Coun to enter ' y P _ u nth a ave mann pr o c i pis osas SEE REVERSE FOR EXPLANATORY LANGUAGE t / U AQ_rw Nre of Appl,Cant or Vert,_ Do,,)/ - - - —'" - - - -