HomeMy Public PortalAbout5312TEMPLE CITY BLVD_Mechanical WORKLRS'COMPFNSATION DPCLARATION - 76A364C - APPLICATION
k PP L IC /k T I O N FOR
PERMIT
I hereby affirm that 1 have a certificate of consent to self CE 818 (2 80) /'1 r r M I V r ft PERMIT
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inside or a certificate of Workers Compensation Insurance or HEATING-VENTILATING-AIR CONDITIONING SIUI'
a certified py t re f 3800 L
Policy
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I�.Certitied copy is hereby furnished - COUNTY OF LOS ANGELES / BUILDING AND SAFETY
�T Cerhfled copy a filed with the count? building I spc� FOR APPLICANT TO FILL IN BUILDING
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UateLCL..�G.`Apphcnni S/J_ (PRINT OR TYPE ONLY) ADDRESST?- v_
CERTIFICATL Of EXEMPTION FROM WORKLRS NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOC ALITV
COMPENSATION INSURANCE NEAREST }
(This section need not be completed if the work involved — ABSORPTION UNIT BTU CROSS ST it
by the permit 6 for one hundred dollars ($100) Or leas) DISTRICT NO PROCESS .6\'-
1 certify that to the performance of the cork for which this AIR HANDLING UNIT CFM jam' eop",
permit Is Issued I shall not employ any person In any manner J O
so as to become subject to the Workers Compensation Laws BOILER BTU _ 6
APPROVALS DATE INSPECTOR SSIGNATURE
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Dale Applicant COMPRESSOR BTU_.ia,-(cifL/V
ROUGH ,[�__,�,�
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL 2
Fxemption you should become subject to the Workers
Compensation provisions of the Labor Code you must forth _
with comply with such provisions or this permit shall be EVAPORATIVE COOLER VALIDATION
deemed revoked FURNACE FAU URAVITV
LICENSED CONTRACTORS DECLARATION FLOOR TU
1 hereby affirm that I am licensed under provisions of Chapter HEATER SUSPENDED UNIT �G
9 (commencing with Section 7000) of Division 3 of the Bust WALL
ness and Professions Code and my license is In full force and
effect `/ (T/
License Numbe-30w+ Iass�
Contractor`
I am exenT'pt from the licensing requirements as 1 am a
licensed architect or a registered professional engineer Plan check fee ')5%of above
acting to my professional capacity (Section 7051 Bus
mess and Professions Code) PERMIT ISSUING FEES,
Ltc or Reg No Date TOTAL FEE
HOMEOWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that 1 am exempt from the Contractor's NAME
License Law for the. following reason (Section 7031 5 Bust
nest and Professions Code) ADDRESS
❑ I as owner of the property will do the work and the $ 1 5 1 9 A
Structure is not Intended or offered for sale (Section CITY TEL NO
7044 Business and Professions Code) p�- / ��� �,� 8
❑ OWNER // `/7 �5�/
I as owner of the property am exclusively contractcontractorsv V�f�Kff 2 -1-2,7 a O
With licensed contractors to constrnstrucc1
t the project MAIL � -
(Section 7044 Business and Profesalons Code) ADDRESS 2 7 O Q
CONSTRUCTION LLNDING AGENCY CIT TEL NO i I (�, 1 ,S-S 1
I hereby affirm that there u e construction lending agency /�J
for the performance of the work for which this permit Is CONTRACTOR
Issued (Sec 3097 Cis, C )
Lenders Name ADDRESS
Lender s Address CITY �� TEL NO
1 certify that I have read this application and state that the STATLIC
above Information is correct I agree to compl) with all County I EN E N d CLASS i
ordmnnas a d State laws re tat mg Heating Ventilating and ,
Au Condnt i ma and hereb a Rhonre representatives of this SEE REVERSE fOR EXPLANATORY LANGUAGE
Count n titer upon t bove men[mned proDen for —
pe.ct m i is sAAl '
a wt of mtttee Dal