HomeMy Public PortalAbout5837-5839TEMPLE CITY BLVD_Mechanical WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I her�aby+affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, E-81 HEATING - VENTILATING - AIR CONDITIONING J1
.,'4TI a certified'copy thereof(Sec. 3800, Lab. C.) CC
CE 818(REV. 10/81)
Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING u�A -5 1.
tion department. (PRINT OR TYPE ONLY)
ADDRESS `,/ZJ J
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work Involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
the permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM ww��• !��(
I certify that in the performance of th work for which this �-J. t/ C�
6V
permit is issued, I shall not employ any pe son in any manner
BOILER,BTU
so as to co a subject to the Work t On Laws. ,/ry /) APPROVALS DATE I CTOR'S SIGNATURE
COMPRESSOR,BTU 6-V /J z7o'
Date w Applicant �� ROUGH
NOTICE TOAPPLICANT: If, after k g this ificat of VENTILATION SYSTEM FINAL
Exemption, you should become su iect to the or ers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA ION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 7000)of Division 3 of the Business. - WALL
and Professions Code,and my license is in full force and effect.
License Number Lic. Class ,
09.
Contractor Date
O
Ell am exempt under Sec.
Plan check fee y
B.BP.C. for this reason PERMIT'ISSUING FEE$ z
Date:
Signature TOTAL FEE-
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ;2 4 8 1,1'A
I hereby affirm that I am exempt from the'Contractor's License Poo. # o o o o:0 8
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
El1, as owner of the property, or my employees with ADDRESS ° -3 (150
wages as their sole compensation,will do the work and =
the structure is not intended or offered for sale(Section CITY TEL. NO. 0 0 0 7J 0'S 0 v
7044, Business and Professions Code).
ow €R
Elp6;1 3 =86
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL MAILADDRE'
Tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS v
Lender's Name
CITY TEL. NO.
Lender's Address
STATE LIC. -.
I certify that I have read this application and state that the LICENSE NO. CLASS
above information is correct. I agree to comply with all County
ordinances and State law elating to building construction,
and hereb a th iz r entatives of this County to enter
Lpon the b roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign ure of licant or A Date