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HomeMy Public PortalAbout4442 TEMPLE CITY BLVD_Mechanical__ WORKER I have PENSATwNDEconsenoN 20-0046 DPW aj a APPLICATION FOR PERMIT LIME GREEN I hereby alhim that I have a certificate of consent to self insure or a gertlficate'of Worker a Compensation Insurance or a certified _ • copy thereof(Sec 3800 Lab C) HEATING•VENTILATING-AIR CONDITIONING Policy No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV ❑ Cert ietl copy is hereby furnished ❑ Combed copy is filed with the county,wilding Inspection FOR APPLICANT TO FILL IN BUILDING department, ad (PRINT OR TYPE ONLY) ADDRESS Dale 'Applkam NO TYPE OF APPLIANCE OR EQUIPMENT 'FEE LOCALrTY CERTIFICATE OF EXEMPTION FROM WORKERSNEAREST COMPENSATION INSURANCE j CROSS ST (This section Mead not be camplated N the work Involved by the ABSORPTION UNITBTU ASSESSOR permit Is for one hundred dollen f the DISTRICT W Or is )or Nu) Mfq R HANDUUNIT MAP BOOK PAGE PARCEL CFM m I certify that In the performance of the work for which this permit �i- le ometl I shelf t not employ any person Compensation any manner so as to BOILER BTU become subject sh to the Workers any person in Lewy T ' COMPRESSOR BTU Date Applicant - M &S DATE IM&£CIIXV a exw km VENTILATgN SYSTEM NOTICE TO APPLICANT a after to the this C ompe sa al gapes 'Exemption you should become yousubjecit M the Workers Campus Such EVAPORATIVE COOLER provisions of the Labor Code-you must forthwith comply with such FINAL � provisions or this permit shall be deemed revoked FURNACE FAU GRAVfTY LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIIYAf ION ir I hereby affirm that I am licensed under provisions of Chapter 8 SUSPENDED—UNIT— Professions USPENDED WJR _ (commencing with Section 7000)of Division 3 of Me Business and NEATER WALL Professions Cade and my license Is In full force and effect ') ' 2 G io Licourn Number L. Cie. ^ 1L Contractor Date' O ❑ i am exempt under Sec Plan check fee U ' fZ B AP C for this rasion PERMIT ISSUING FEE$ (p �. O _ � H Date TOTAL FEE W Signature Il OWNER-BUILDER DECLARATION PLM!CHECK APPLICANT (n- - - Z I hereby affirm that I am exempt from the Contractor a License Law NAME , for the following reason (Section 7031 S Business and Professions 12 Code) v ADDRESS 14 _ © I as owner of the property or my employees with wages k 1 .i as their sole compensation will do the work and the CITY TEL NO ,,nT�7 structure Is not intended or offered for sale (Sect / "'`'L,r -i•��1 Business and Professions Code) 2 OWNER 1 ITEMS I as owner of the property errf ekc uel Ivaly conir with licensed contractors to construct the project (Sec ADDRESS ' TOTAL 21 - 60 i Iron 7044 Business and Professions Code) CITY TEL NO CONSTRUCTION LENDING AGENCY I hereby rman e f there lee for this lending agency for CHANCE the performance t of the work for which thio permit a Icy for _ r (Sac 3087 Civ C) _ _ ^_ i .v O( I '.•• If " ADDRESS — _ _ _ Lander a Nemo CT' TEL NO LanaeraAddress 411­62 1_ AM .1:7,- STATE LID I cartlly,that I have read this application and state that the above LICENSE NO CLASS Information of coned I agree to comply with all County ordmonce, and State levee relating to willing construction and hereby author¢e representatives of this County to enter u he above-mentioned property for Inspection purposes f SEE REVERSE FOR EXPLANATORY LANGUAGE r s> =