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Home My Public Portal About5329TEMPLE CITY BLVD_Mechanical (2) WORKERS COMPENSATION DECLARATION 78A384C I hereby affirm that I have a certificate of COMLnt to self GE BIB (z BO) APPLICATION FOR PERMIT ((( insure or a certificate tit Workers Compensation Insurance or I HEATING-VENTILATING-AIR CONDITIONING a certified cops thereof(See 3800 Lab C ) Policy No Company ❑ LLnified copy Is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is filed with the county building inspection BUILDING department FOR APPLICANT TO FILL IN p Date Applicant (PRINT OR TYPE ONLY) ADDRESS—1 Gf1tA4 LOCALITY Ch RTII ICATE Of EXEMPTION rROM WORKLRS NO TYPE OF APPLIANCE OR EQUIPMENT FEE o_LIVb COMPENSATION INSURANCE NEAREST _ > (This Section need not be completed If the work Involved ABSORPTION UNIT BTU CROSS ST - 0 by the permit 19 for One hundred dollars (SIUU) Of Im) - DISTRICT NO PROCESSED BY - 0 1 certify that in the performance of the work for which this AIR HANDLING UNIT CFM K permit is issued 1 shell not employ ) person m any m nu O so as to become sub)ecI to the W er5 Com n ation ws BOILER BTU15 ��f.�J/�� APPROVALS DATE INSPECTOR S SIGNATURE yWy Datc4psR�p.•.aafppllc _ COMPRESSOR BTU—_ ROUGH 4 � NOTICE f0 APPLICANT If after makmL us Cern hcate VENTILATION SYSTEMon Exemption you should become sub)ect to the Wor s FINAL _ Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deemed n.vokeJ FURNACE FAU_ GRAVITY— LICENSED RAVITYLICLNSED CONTRACTORS DECLARATION FLOOR BTU I herebv affirm that I am licensed under provisions of Chapter HEATER SUSPENDED UNIT 9 (commencing with Section 7000) of Dn¢ton 3 of the Busi WALL ness and Professions Code and my license is in full force and -� effect I.ICense Numbly Lm Class Contractor Date ❑ I am exempt from the licensing requirements as 1 am a licensed architect or a registered professional engmeLr Plan check fee ')5%of above acting In my prof"sional Lapacity (Section 7051 Bus mess and Professions Code) PERMIT ISSUING FEE $ Q Lic or Reg No Dale TOTAL FEE HOME OW'NPR BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that 1 am exempt from the Contractors NAME ,tea License Law for the follovnng reason (Section 7031 5, Busi — ness and Profusions Code) ADDRESS ❑ 1 as owner of the property will do the work and the --r structure is not Intended or offered for sale (Section CITU Taw�L �rf1L+�- TEL NO 0 b 1 5 A 7044, Business and Professions Code) I�'� " Y1 LiY 1 1 ` ❑ y g OWNER 1, as owner of the # �'• • 8 property am exclusively controLtin ' woh licensed contractors to construct the proleLt MAIL I f (Section 7044 Business and Professions Code) ADDRESS __ )I I•�' 2 Q 5 0 CONSTI4UCTION LLNDING AGENCY CITY TEL NO i�tu 2 Q 5 0 I htreby affirm that there Is a construction lending agency fur the pLrfotmance of the work for which this permit Is CONTRACTOR 1 b — 8 3 Issued (Sec 3097 Civ C ) Lender s Name ADDRESS LLnder s Address CITY TEL NO _ - 1 certify that I have read this application and state that the STATE LIC above information w correct 1 agree to comply with all County I LICENSE NO CLASS ordinances and State laws reguluting Heating Ventilating and Air Condi ionmg and hereby aulhonze representatives of this SEE RI VERSE I OR EXPLANATORY LANGUAGE Count w enter upon th aboie menhoned properly for Lhnn I ^� Signature of Pe ,ttee Date l� -