HomeMy Public PortalAbout4829TEMPLE CITY BLVD_Mechanical 54, L' �7 - 30 ^-7 "
WORKER I haveCOMPENSATION
icate of consent
70A3W a/Ba APPLICATION FOR PERMIT LIME GREEN
I hereby affirm that I have a certificate of consent to self insure ]fl�lTesC
_or a cenificete of Worker a Compensation Insurance or a certified HEATING-VENTILATING-AIR CONDITIONING
copy tbereof(Sac 3800 Lab C) I Ll
.No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
Certified copy is hereby hKniehed
Certified re filed with the county building InaPSclgn FOR APPPment �LICCATNTT TO FILL IN BUILDING '
ADDnEss I e Crt 1 (!.-
I NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCAOTY
CERTIFICATE OF EXEMPTION FROM WORKERS NEMFST N
COMPENSATION INSURANCE - CR059�
(This section need not be completed If the work Involved by the ABSORPTION UNITBTU ASSESSOR - _ -
permN In for one hundred dollen(i/00)or Nu) NMAP BOOK PAGE PARCEL
R HANDLING UNITCFM pl*fgCr Lp
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,BTU
become subled to the Workers Compensation Laws fJ—f U ev ,
I COMPRESSOR BTU
Date Applicantrsveg+xu an werccmeaeaw.nxLe
VENTiLAT10N SYSTEM
NOTICE TO APPLICANT If alter making this Certificate of _ ROUGH
Exemption you should become subject to the Workers Compensation
provisions of the Labor Code you must lorthwth comply with Such EVAPORATIVE COOLER FINAL
provisions or this permit shell be deemed revoked FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I em licensed under provision* of Chapter 9 SUSPENDED—UNIT—
(commencing
USPENDED UNIT_(commencing with Section 7000)of Division 3 of the Business and HEATER WALL 2-.COvy n n)
Professions Code and my license Ia In full force and effect
License Number Lic Clew
a
Contractor Data _
❑ I am exempt under Sec Plan Check fee r
2
B aP C for this reason PERMIT ISSUING FEE$ O
Date TOTAL FEE W
Signature �-
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT , _ Z
I hereby affirm that I am exempt from the Contractors License Law NAME , Al I.T,1
T'
for the following reason (Section 7031 6 Business and Professions
Code) ADDRESS 36TJ7 Lrj,U.i I
❑ I as owner of the property or my employee* with wages 1 ITEM
as their Sole compensation will do the work and the CITY TEL NO -
structure is not Intended or offered for sale (Section 7044 � TOTAL 25 -00
Business and Professions Code) OWNER
❑ I as owner of the property am exclusively contracting CHECK 255.1313
MAIL
with licensed contractors to construct the project (Sea- ADDRESS CHANGE 00
tion 7044 Business and Professions Code)
CITY TEL NO
CONSTRUCTION LENDING AGENCY ,
I hereby affirm that there Is a construction lending agency for
the performance of the work for which this permit Is Issued CONTRACTOR 'fi. - 6005 (5)10 -Lde — _ _ 131100—L001 5J/15191
(Sac 3097 CN C) - _ 1
ADDRESS� 0,1
� 6S5U 1 AM 0%U_
Lender a Nerve ,
CRY TEL NO ' -
Lender a Addrew STATE LIC
I certify that I have read this application and state that the above LICENSE NO Q CLASS
information is correct I agree to comply who all County ordinances
and State laws relating to building construction,arM hereby aulhorae -� I
representatives of this County to enter upon the above-mentioned ,
property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
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