HomeMy Public PortalAbout5824-5824 1/2-5826TEMPLE CITY BLVD_Mechanical (2) WORKERS'COMPENSATION DECLARATION . ' APPLICATION FOR PERMIT
hereby,effirm'that I have.a certificate of consent to self )
nssure, or a certificate of-Workers'Compensation Insurance,
r a certified copy thereof•(Sec. 3800;Lab. C.) 7¢A3baC HEATING':- VENTILATING - AIR CONDITIONING ,
SCE-818(REV. 10/81)
olicy,N.o. Company ; ? "
Certified copy is hereby furnished. 1 COUNTY 011 LOS ANGELES: I' BUILDING AND SAFETY
Ce'rtified.copy is filed with the county building inspec- FOR APPLICANT TO'-FILL IN BUILDING
tion department. I (PRINT OR TYPE ONLY) ADDRESS
LOCALITY
ate Applicant I F /ample
NO. TYPE OF APPLIANCE OR EQUIPMENT. FEE
CERTIFICATE'OF
EXEMPTION FROM WORKERS'' ' NEAREST
EM
' COMPENSATION INSURANCE - IN ' . 11 CROSS ST.
I' ABSORPTION UNIT,BTUDISTI}ICT N PRO E D BY
his seefion need not be completed if the'wo�k Involved by II li
e permit is for one hundred dollars($100)or less:) f AIR HANDLING UNIT,CFM' /
certify that in the performance of the work for which this I '
rmit.is issued, I shall not employ any person in any manner
as to'become subject to the Workers'Compensation Laws. I BOILER,BTUa ' APPROVALS DATE INSP CTOR'S SI URE
�' COMPRESSOR, BTU �✓ ROUGH14 f
:te 'fr e__94 Applicant �'
TILE TO APPLICANT: If, after making thi 'C rtificate Of ,VENTILATION SYSTEM FINAL
emption,•"you should become subject to the' Workers'
mpensation provisions of the Labor Code, you,must forth- EVAPORATIVE COOLER ,: VALIDATI N
ith comply with such provisions or this permit-shall be
erred revoked. FURNACE: FAU GRAVITY t
LICENSED.CONTRACTORS DECLARATION FLOOR BTU D
ereby affirm that I am licensed under provisions of Chaptei 9 HEATER: SUSPENDED UNIT I ;
mmencing With Section 7000)of Division 3 of the Business ' WALL
d Professions Code,and my license is in full force and effect. I CL
j
ense Number Lic. Cldss _ J
Q9
ntr'actor Date + O
V
I am exempt under-Sec. W
Plan check'fe:e a
'B.BP.C. for this reason' I I N
PERMIT.ISSUING FEE$
Date:
TOTAL-FEE-
Signature r
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT t
ereby affirm that I am exempt from the Contractor's License
for the following reason (Section 7031.5, Business and NAME' •� L 1VIL A Poo". _
fessioris Code): _ -
A /� JJ
as owner of the property ?DRESS
, or my employees with
wages as their sole compensation,will do the work and
the structure is not.infended or offered for sale(Section CITY`��Y�. f e� TEL. NO.•Ze�� (/
7044, Business and Professions Code). R _
OWNER '
I, as owner of the property, am exclusively contracting -- c —
with licensed contractors to'construct the project (Sec- MAIL I _ _ _rf�
tion 7044, Business and-Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY
' CITY , •, :• TEL. NO:
�reby affirm that.there is a construction lending agency for
performance of the work for which this permit is issued CONTRACTOR
c. 3097, Civ. C.). ' .
ADDRESS
der's Name
CITY' TEL. NO.
de.r's Address -
STATE LIC.
ertify that I have read.this application_and,state that the .LICENSE NO. CLASS , ••
ove information.is.corre'ct. I agree to comply with all County j
finances and State laws relating to building•construction,, I.
hereby authorize representatives of this County to enter
on the above-mentioned property for inspection purposes. . SEE REVERSE FOR EXPLANATORY..LANGUAGE
'a re of Applicant or Agerit Date c '