HomeMy Public PortalAbout4452-4454-4456-4458 TEMPLE CITY BLVD_Mechanical__ WL'RKERe CQ'QNSATION DECLARATION
rebr affrrn>,jhaj-I hove a cenlf,cate of <ansent t eel( ... f,� APPJAELES
A IQN FSR' PERMIT_ t -
Insure br C<erna of Workers Compensot�on Inca nce 7� � — — HEATINENTILATING - AIR CONDITIONING
or a certified copy therdsP(Sec 3800, Lab C ) -
CE 816(REV 10/81) _
Policy No Company
Certified copy is hereby furnished COUNTY OF LOS s BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FIL� IN t BUILDING 4 C r/ Y
hon department ADDRESS /i J
(PRIM OR TYPE ONLY)
F/Dote ' Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
// COMPENSATION INSURANCE CROSS ST aC—
(This section need not be completed If the work Involved by ABSORPDON UNIT BTU DISTRICT NO ROPSSED BY -
tho p'mit Is for one hundred dollars ($100)or less) ' AIR HANDLING UNIT CFM
i I certify that m the performance o th work for which this (�LVQ i
permit Is issued, shall not employ n person in any To
r BOILER BTU
so a5 to beco a su t the Wo a Comp sallon /1 /{ APPROVALS DATE OR S SIGNATURE
/ COMPRESSOR BTU14 V OL/ ROUGH
Dote plicant
NOTICE I If after making this Cert i to of VENTILATION SYSTEM FINAL
Exemptio , you hould become subject to the Workers _
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLERVALIDAT46N
with comply with such provisions or this permit sholl be
deemed revoked FURNACE FAU
LICENSED CONTRACTORS DECLARATION FLOOR BTU �r
I hereby affirm that I am licensed under provisions of Chapter 9HEATER - SUSPENDED UNIT_
i (commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code and my license min full force and effect d
License Number LIc Class — - , 13 0 2 5 A V
' Contractor Date # • • • • • 8 C
❑ lam exempt under Sec Lu
Plan check fee • 9 Q I • 5 0 d
B 8P C for this eason N
i
Date PERMIT ISSUING FEES • • • 9 Q 5 0 3 z
TOTAL FEE
5e�1 o927-85
� OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
`\ 1 I hereby affirm that I am exempt from the Contractor s License ,
Low for the following reason (Section 7031 5 Business and NAME
'Professions Code)
1 as owner of the property or my employees with ADDRESS
I wages as their sole compensation will do the work and CITY TEL NO
the structure is not intended or offered for sale(Section
7044 Business and Professions Cade)
❑ OWNER
I as owner of the property am exclusively contracting
with licensed contractors to construct the project (Sec '`RAIL
hon 7044 Business and Professions Code) ADDRESS
— CONSTRUCTION LENDING AGENCY CITY TEL NO - -
hereby affirm that there is a construction lending agency for
1 the performance of the work for which this permit is issued CONTRACTOR
(Sec 3097, Civ C)
ADDRESS 61 - -
Lender s Name
CI OI -
Lender s Address Ale TEL
i STATE LIC ra
I certify that I have read this application and state that the LICENSE NO CLASS
above m(orm Iron a correct I agree to comply wnh all County
orDI D n s o State laws relating to bulldmg consiruchon, _ _ _ _
and her by tho'" representohv sof thrs Count to ent -
upon th ab a manna d pro for Inspection urpose / SEE REVERSE FOR EXPLANATORY LANGUAGE
J
Signature of AppLca ni or Agent a - "