HomeMy Public PortalAbout5801-5803-5805TEMPLE CITY BLVD_Mechanical (2) ION
DECLARATI
WORKER'S I have
a certificate
of consent to 76-A0364C PW9/e9 APPLICATION FOR PERMIT LIME GREEN
I I,areby..ltl+w,m that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance,(&certified
HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.) "0
Onll�
Policy��� �ompany OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
Certified copy is filed with the count building inspectio FOR APPLICANT TO FILL IN BUILDING
ADDRESS
apartment/t (PRINT OR TYPE ONLY) �n 3 ��
Date I J/"lA Applican LOCALITY �-
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
� CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. P OCEl SED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER.BTU (/
become subject to the Workers'Compensation Laws.
�D
/ COMPRESSOR,BTU �O
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR -BTU-
VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
License Nu be Lic.Cle a�
® E C
ContractoA10-i Date -A y C
F1 am exempt under Sec. Plan Check fee ACCT.4 G
B.&P.C.for this reason PERMIT ISSUING FEE$ �(� 3303 80.50 C
Date: TOTAL FEE U 1 ITEMS L
ll
Signature TOTAL 80-°0 U
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT CHECK 80.50 3
1 hereby affirm that I am exempt from the Contractor's License Law NAME ® CHANGE .00for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS
I, as owner of the property, or my employees with wages i{!�000r�r'� n�•y
as their sole compensation, will do the work and the CITY TEL.NO. 0 "0001 5/ 7/96
structure Is not intended or offered for sale(Section 7044, 1
Business and Professions Code). OWNER M 'S v
78 1 AM 11 49
E3I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,Business and Professions Code). nn
CONSTRUCTION LENDING AGENCY CI TEL.No X
I hereby affirm that there is a construction lending agency for CONTRACTOR vv�1vv
I performance of the work for which this permit Is issuedWn(Y Co
(Sec.3097,Civ.C.).
ADDRESS
Lender's NameIftli
CI TEL.NO.
Lender's Address STATE LIC. �)
I certify that I have read this application and state that the above LICENSE NO. CLASS 0,
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
Uaw
for inspection MI SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE 'F d T DATE