HomeMy Public PortalAbout5005TEMPLE CITY BLVD_Mechanical (2) ! _. :
• ti WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
Insure, or a certificate of Workers Compensation Insurance HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec 3800177 Lab C ) /,._ I,.� 7eA3e4C i
�' y Zow Id/SLA[�1CG do e18(REV 10/81)
Policy No ASO y 1ampan
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
E_ Certified copy is filed with the county building mspec - FOR APPLICANT TO FILL IN- aunDING
hon de nment (PRINT OR TYPE ONLY) ADDRESS5oos SLyn
Date Applicant
`/, ,/:C. �i(�A LOCALITYNO TYPE OF APPLIANCE OR EQUIPMENTFEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE CROSS Si
(This section need not be corrrplafed If the work Involved by ABSORPTION UNIT BTU DISTRicr NO P SSEo er
thepermit Is for one hundred dollars ($100)or less ) Y
I certify that in the performance of the work for which this AIR HANDLING UNIT CFM S( L
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 IN TORS SIGNATURE
Date Applicant COMPRESSOR BTU (/ ROUGH LL
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 VALIDATICI
with comply with such provisions or this permit shall be
' deemed revoked FURNACE FAU GRAY TY /D
LICENSED CONTRACTORS DECLARATION FLOOR BN
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT_
(commencing with Section 7000) of Division 3 of the Business WALL }
and Professions Code,and my license is in full force and effectD.
- -
License Number quI IJU 2_Lic Class A_rJ0.®' ' 2 7 2 9 A K
Contractor r ate O
g . . . . . g G
I am exempt under Sec Plan check fee 1 . • 3 Q 5 0 N
B 8P C for this reason PERMIT ISSUING FEES Q Z
Dote 3Q50�i
Signature
TOTAL FEE SO
- OWNER-BUILDER DECLARATION RAN CHECK APPLICANT Q Q 1 b+S 5
1 hereby affirm that I am exempt from the Contractor s License ,
Law for the following reason (Section 7031 5 Business and NAME
Professions Code) �j�
❑ I as owner of the property or my employees with ADDRESS r ✓
wages as their sole compensation will do the work and
the structure is not intended or offered for sale(Section CITY ijTEL NO Z
7044 Business and Professions Code)
OWNER
❑ I as owner of the property am exclusively contracting
with licensed contractors to construct the project (Sec MAIL
tion 7044 Business and Professions Code) ADDRE ^
CONSTRUCTION LENDING AGENCY CITY TEL NO
I hereby affirm that there is a construction lending agency for polo performance of the work for which this permit is issued
(Sec 3097 Cv C ) CONTRACTOR E sJIM hip 1
ADDRESS 0abu Silo
Lender's Name
TEL NO _
Lenders Address f "
ertify that I have rood this application and state that the LIQNSE NO TE Cu55 CIO A8,
Quve information is correct agree to comply with all Caunry
n ces and State I relating to building construction
eby
out a relating
of this County to enter '
n e above n d property for inspection purposes REVERSE f-0R EXPLANATORY LANGUAGE _
m of Applicant or ant U Date