HomeMy Public PortalAbout4500-4502-4504-4506 TEMPLE CITY BLVD_Mechanical__ // WORKERS'COMPENSATION DECLARATION 1 1 •` r
4 here0y offrrm.thot I<ve a certificate of consent to self APPLICATION FOR PERMIT
uoLre or d'cerrificots of Workers Compensation Insurance HEATING - VENTILATING - AIR CONDITIONING
,.A or a cergdi;r co,) Plereof (Sec 3800, Lab C ) CE g g(REV IDiBt) - - - -
Policy No Company
❑ Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY `E
❑ Certified copy is filed with the county building inspec FOR APPLICANT TO FILL IN BUILDING `�� 21 Q/ �I
tion deportment (PRINT OR TYPE ONLY) _ ADDRESS a (7
Date Applicant LOCALITY .
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE CROSS 57 A_
(Thiss*Mon need not be completed If the work Involved by ABSORPTION UNIT BTU DiSTRiCiHo [ a BY
fhe perrrtlt Is for ote hundred dollars ($100)or first, ) AIR HANDLING UNIT CFM r
I certify that in the performance o the work for which this 5Fo
permit is issued I shall not employ y rson in any manner BOILER BTU
so as to bec me au lect to the Wor s ompen on APPROVALS DAN BvsPE sx-x,
Date ppticant COMPRESSOR BTU IM ROUGH
NOTI A I T I( after making this Cerhfl t of VENTILATION SYSTEM FINAL
Exemption yo should become subject to the orkers _
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VALIDATI N
i with comply with such provisions or this permit shall be
deemed revoked fURNACE FAU D
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 f 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 - Y
O
License Num Lc Class — ► , 13 0 2 6 A K
IM
Controctor Date # e e P e e 8 r
❑ I am exempt under Sec Plan check fee 1 -'- 9(150 d
B 8P C for this
a on N
DatffW/IffPERMIT ISSUING FEES 5 e e • 9 Q 5 0 5
Signature TOTAL FEE
OWNER BUILDER DECLA T N PIAN CHECK APPLICANT o9.27-85
I reby affirm that I am exempt from the ontractor s License
for the following reason (Section 7031 5 Business and NAME
ssions Code)
I as owner of the property or my employees with ADDRESS L
wages as their sole compensation will do the work and CITU , TEL NO '
x' cture is not intended or offered for sale(Section
Business and Professions Code) -OWNER
owner
owner of the property am exclusively contracting
I consed contractors to construct the project (Sec MAIL
Business and Professions Code) ADDRESS
CONSTRUCTION LENDING AGENCY CITY - • - - TEL NO -
um that there is a construction lending agency for
once of the work for which this permit is issued CONTRACTOR H V ►
ADDRESS a R iz
Name
CI D TEL NO
s Address -
TATE tic
ify tJ� nd
I have read this application and state that the LICENSE NO CLASS
anon is correct I agree to comply with all County
n State laws relating to building constructioner uthonze represe es of this C myt enterve-ment ed p ty for ins pe ion p poses SEE REVERSE FOR EXPLANATORY LANGUAGE
of Applicant or Agent Date -
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