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Home My Public Portal About5537TEMPLE CITY BLVD_Mechanical (2) I/ WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have o certificate of consent to self Insure or o certificate of Workers Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING T or a certified copy thereof(Sec 3800 Lob C J CE 818(REV 10/81) Policy No Company Certified copy is hereby furnished COUNTY OF LOS ANGELES 7r BUILDING AND SAFETY ❑ Certified copy is filed with the county building innpec • FOR APPLICANT TO FILL IN BUILDING T tion department (PRINT OR TYPE ONLY) ADDRESS 'C Dote Applicant LOCALITY NO TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST COMPENSATION INSURANCE CROSS 57 (This section need not be completed If the work Involved by ABSORPTION UNIT BTU DRTRICl NO SSED BY the permit Is for one hundred dollars($100)or Iws ) AIR HANDLING UNIT CFM I certify that in the performance of the ork for which this permit Is is ued shall not employ any er on in y manner so as to cam ublect to the Work e ' mpe t Lows BOILER BTU APPROVALS DATE INSPECTOR s si ATDRE Dot plicont COMPRESSOR BTU ROUGHI fiq-g AA 114 N ICE T APPLICANT If after okmg this ihcate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers Compensotion provisions of the Labor Code you must forth- EVAPORATIVE COOLER VALIDATI with comply with such provisions or this permit shall be deemed revoked FURNACE FAU GRAVITY" LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED—UNIT— (commencing USPENDED UNIT_(commencing with Section 7000) of'Dlvavon 3 of the Business WALL and Professions Code and my license is in full force and effect r // I License Number 701 y J Lic Class - 100 OL Contractor LS UDote ,mss (0I� ❑ I am exempt under Sec sem$ Plan check fee d B 8P C for thnr = PERMIT ISSUING FEES O U GY to p pa IF SignatureTOTAL FEE OWN BUILDER DECLARATION RAN CHECK APPLI I hereby off em that I am exempt from the Contractor s License Law for the following reason (Section 7031 5 Business and NAME Professions Code) ❑ I as owner of the property, or my employees with ADDRESS 0725-84 wages their sole compensation will the work and CITY TEL tJ0 the structure is not intendfoed or offered for sole(Section 7044 Business and Professions Code) ?STA ❑ I as owner of the property am exclusively contracting PU wish licensed contractors to construct the project (Sec tion 70" Business and Professions Code)) CONSTRUCTION LENDING AGENCY PN TEL No 3 L� I hereby affirm that there is a construction lending agency for ' 7 , the performance of the work for which this permit is issuedCTO (Sec 3097 Civ C ) _ Lenders Name TEL G/ b^I O Lender sAddress .� 30$4s ZSS a �ertify that I have recd this application and state that the !O _ Obove i motion is correct I agree to comply with all County ordma a and State I s relating to budding construction and h r y authorize a sentativas of this C my t anter upo above- o property for Ins tion p oses SEE REVERSE FOR EXPLANATORY LANGUAGE _ /` Sign Nre of AppLwnt o nt to �!