HomeMy Public PortalAbout4805TEMPLE CITY BLVD_Mechanical (2) WORKER SCOMPENSATION DATION DPW efee APPLICATION FOR PERMIT UME GREECE
I hereby efin,n that I have a certlllcete off consent to Bell Insure 7&k164C
or a certificate of 14orker a Compensation Insurance or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec 3800 Lab C)
Poh6yNo Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
ElCertified copy Is hereby furnished
❑ Certaretl copy le filed with five county building Inspection FOR APPLICANT TO FILL IN BUILDING rJ G
tleperimem (PRINT OR TYPE ONLY) ADDRESS
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DeeL
�� NO TYPE OF APPLIANCE OR EQUIPMENT FEE 6,T
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
CROSS ST
COMPENSATION INSURANCE ABSORPTION UNIT BTUASSESSOR H�
(This section need not be completed If the work Involved by the DU C/ PARCEL
permit Is for We hundred dollars(7100)or leu) AIR HANDLING UNIT CFM MAP BOOK PAGE a AP B as
I certify that In the performance of the work for which this permit
is issued I shall not employ any person In any manner so as to BOILER BTO
become subject to the Workers Compfigavion Laws /n]
`Dm'dr COMPRESSOR BTU
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Oele cant
VENTILATION SYSTEM
NOTI ETO fk a
ROUGH - x
Exemption you Mould become subject to the Workers Campensatron T
provisions of the Labor Code you must forthwith comply with Buch EVAPORATIVE OWLER / �/ FINAL
provisions or this permit Shall be deemed revoked FURNACE FAU_GRAVITY
LICENSED CONTRACTORS DECLARATION - FLOOR BTU VALIDATION
1 hereby affirm that I am licensed under provisions of Chapter 9 - SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Businats and HEATER WALL
Professions Code and my license Is In full force and effect
License Number 3/af Lb pma116 ACCT.:
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Coniractac Lff/t�Date d - amu
42.15 V
❑ I ern exempt under Ssc Plan check fee 1 ITEMS
B SP C for this reeson - PERMIT ISSUING FEE$ 4p TOTAL 43 - 1.5 O
H
Date TOTAL FEE / CH��E�CK 4 .15 W
Signature CTAKE .1113 d
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT _ z
Z
I hereby affirm that I am exempt from the Contractor a License Law NAME �l ate- - - ► ��nr1Vu 1 ],/`4/ '
for the following reason (Section 7031 5 Business and Professions </
Code) O
ADDRESS
I as owner of the property or my employees with wages " '�8 .11sA0 A2 /D—• O, 'j 1 F��LU:1�
as their sole compensation will do the work and the CRY TEL NO o?-0
structure is not Intended or offered for sale (Section 7044
Business and Professions Code) OWNER O V w
❑ I as owner of the property em exclusively contracting MAIL �qn
with licensed contractors to construct the project (Sec AD MAIL
L,/p64 p '
tion 7044 Business and Professions Code) _
Cfry TEL
CONSTRUCTION LENDING AGENCY '
I hereby affirm that there nsa construction lending agency for
the performance of the work for which this permit a Issued �� �� ► -
(Sec 3097 Cis, C)
ADDRESS —
Lender a Name O _
CRY / TEL NO
I- Q ,B
edx S Address STATE O LIC Q -
I certify that I have read this application and state that the above UCEF19E NO CLASS
information is correct I agree to comply with all County ordinances _and State laws relMng to budding construction and hereby authorize
representatryrs County to enter upon the abova-mentioned
property nap tion purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
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