HomeMy Public PortalAbout4333 TEMPLE CITY BLVD_Mechanical__ WORKERS COMPENSATION DECLARATION APPLICATION ION FOR PERMIT
I hereby affirm that I have a certificate of consent to self ti
irmurc, or a cernfncate of Workers Compensation Insuranceti
or a certified copy thereof (Sec 3800 Lab C ) 764364c ' HEATING - VENTILATING - AIR CONDITIONING
• CE 818(REV 10/8I) - - -'
Policy No Company
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
r
Certified copy is filed with the county building mspec FOR APPLICANT TO FILL IN BUILDING A
tion department (PRIM OR TYPE ONLY) ADDRESS 3 TlfM LG L/T ✓aK
Date Applicant NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE ' I CROSS ST ✓r7A-'.✓pi,JiJ
(This stolon need not be completed H the work Irnolved by ABSORPrION UNIT BTU DISTRICT No PROCE r
the permit Is for one hundred dollen($100)or loss )
s AIR HANDLING UNIT CFM L'� /s O
I permit
that d the performance a the work for which this J (/
permit is issued, I shall not employ any person in any manner BOILER BTU
so as to become subject to the Worker Compensation Laws Alweovnls DATE iN aoas sIGN 1nRE
Date✓ 'LY -�.J I,con y.,,_ COMPRESSOR BTU ROUGH Q
NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDAT N
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 -
r`�/ O
License Number Z 0(-T g� 8 Lit: Class 2'67 V
/ Q Os
Connactor��?/J C 41� Dote A+ 2-V-,f IOr.
I am exempt under Sec V
Pian check fee L"
B 8P C for this reason Cl.
Date _ _
PERMIT ISSUING FEE $ Z
Signature TOTAL FEE -
OWNER BUILDER DECLARATION RAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor s License pop.Law for the following reason (Section 7031 5 Business and NAME
Professions Code)
❑ I as owner of the property or my employees with ADDRESS
wages as their sole compensation will do the work and
the structure is not intended or offered for sale(Section CITY TEL NO
704, Business and Professions Code) - - - - _
OWNER❑ D✓/6/L�CCO I as owner of the property am exclusively contracting
with licensed contractors to construct the prolect (Sec MAIL - - -'
non 7044, Business and Professions Code) ADDRESS 7v /4risr 7 ��•�
CONSTRUCTION LENDING AGENCY CITY - TEL NO - - - ;F 2 3 L 0 A �
—',-1 hereby affirm that there iso construction lending agency for__ _ r
__ _ _ _ _ ____r__ _____,_ _ __ _ __ ___
the performance of the work for which this permis issued CONTRACTOR ADDRESS O _ __ ___
- -- - — — -' ' - 8'=--_
(Sec 3097 Civ C )
✓ ETx./ -VC . - _ __ I i• • 20 50
Lender s Name
CITY TEL NO _ i • 020
506
6
Lenders Address - _
1 certify that I have read this application and state that the LICENSE NO 2.806 y8 CLASS
IA LIC , O 6 2 4 i 8 5
above information is correct I agree to comply with all County -
ordinances and State laws relating to budding construction,
and hereby authorize representatives of this County to enter
the v e t ned property for inspection purposest
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant m Agent Dob
I