HomeMy Public PortalAbout4505 TEMPLE CITY BLVD_Mechanical__ `/JORKEI have aENSAT1oN of consent
sf� APPLICATION FOR PERMIT LAME GREEN
I heres}ixium ihef I have a certificate of connsnt to sell Insure
or a cer lfica�e of Worker s Compensation Insurance or a cenilied HEATING-VENTILATING•AIR CONDITIONING
copy thereof(Sec 3800 Lab b)
Policy No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
❑ Carolled copy IS hereby furnished
❑ Certified copy Is filed with the county building innpecbon FOR APPLICANT TO FILL IN Wig$ 5'OS' ��...P1E C� ���
department (PRINT OR TYPE ONLY)
Date AppliceMLOCALI Y
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
^
't - COMPENSATION INSURANCE ABSORPTION UNIT BTU CROSS ST 1
(Thisssitfen need not be m
ceplNiM N Involvework Inrod by the MAPBOOK p��C. PAGE ASSESSOR 4v%ci( PARCE
permit Is for one hundred dollars($100)or IS")
pIWf.'r
Ou0 moceeem ev
1 certify that In the to employ
an of the work for which this permit
to
is Issued I shell not employ any person In any manner so ea to BOILER BTU •
become subject to the Workers Compensation Laws - O
- COMPRESSOR,BTU 3
Arenovua DATE eeorwtuim
Data AppVENTILATION SYSTEM .�.�
NOTICE TO APPLICANT IIt after making this Certificate of ROUGH
Exemption YOU Should became Subject to the Workers Compensation EVAPORATIVE COOLER
provisions of the Labor Code you must forthwith comply with such �— FINAL
provisions or this permit Shall be deemed revoked FURNACE FAU_O `
LICENSED CONTRACTORS DECLARATION FLOOR BTU 3 i VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 8 HEATER SUSPENDED UNIT_
(commencing with Section 7000)of Divielon 3 of the Business and WALL
Professions Code and my license is In toll force and effect
a
License Number Lic Clore dd
Contractor Date -
I em exempt under sec Plan check fee O
B dP C for this reason PERMIT ISSUING FEE$ T s. y.; ' ' - 0
g
Dee TOTAL FEE _ AMA
OW
Signature OWNER BUILDER DECLARATION PLAN CHECK APPLICANT _ _ _ 'i : 17 117.21 ?
I hereb affirm that I em exempt from the Contractor a License Lew NAME ► _ JaV 1 � _
for i following reason(Section 7031 S Business and Professions r;-
COA ADDRESS _.._
I as owner of the propertyTOTAL 117.21,
/D7LylA
or my employees with wages •.._ ,L' Et�/CyK/ 117 21
as their sole compensation will do the work and the CITY TEL NO - I•+ VI `
structure Is not intended or offered for sale (Section 7044 -in-- - t y�I/L�S�� - .�
Business and Professions Code) R , _ ,\ Ik T.4@w1TS
❑ I as owner of the property am exclusively contracting i
with licensed contractor. to construct the project (Sec ADDRESS QS' C r •� .s!'� t �y�,_L � n
tion 7044 Business and Professions Cade) �.� f 0000-=1 9/ L
CONSTRUCTION LENDING AGENCY CITY /•�� C/. "O ` 30 J ` 5306 1 All11=15
I hereby affirm that there is a construction lending aggency for
the performance of the work for which this permit is leeued pop - --
(Sec 3087 Ch, C)
ADDRESS +
Lender s Name
CT' TEL NO
Lender a Address STATE LIC - -
I certify that I have read this application and state that the above LICENSE NO CLASS
information is correct I agree to comply with all County ordinances _
and Slate laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
property for Inspection purposes BEE REVERSE FOR EXPLANATORY LANGUAGE
TAE aF APP p1 AOENrowe