HomeMy Public PortalAbout4830 TEMPLE CITY BLVD_Mechanical__ WORKERS AveMPENSATION DECLARATION
that APPLICATION FOR PERMIT
I heaeyy aff6m at I ve a cer�flcate of convent to self
insure or a cerfifrcate of W rkers CAampensahon Insurance - HEATING - VENTILATING - AIR CONDITIONING
or o certified copy thereof (Sec 3800 Lab C ) _ 76A36*C '
CE 818(REV 10/81)
Policy No Company
❑
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy .s filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING (I,p Thu �, 8I
tion department (PRINT OR TYPE ONLY) ADDRESS +
Dote Applicant LOCALITY TeI-G Q. ca 91780
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE I CROSS ST 1-OVCI fiI
ABSORPTION UNIT BTU 100, 000 DISTINCT w PRaCE D Y
(This section need not be completed if the work Inrolred by the permit Is for one hundred dollen($100)or less) (�
d
I certify that In the performanc+e of the work for which HANDLING UNIT CFMh this r
permit Is Issued, I shall not employ any person In any manner BOILER BTU
so as to become subject to the Worke'R, mp�eEn�sattlon Laws APPIDVALS DATE DR S sI TORE
Data Applicant
I aliOlsS V (9.4 CL-- COMPRESSOR BTU 100, 00o a,f ROUGH
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 VALIDATIO
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU_GRA T ,1
LICENSED CONTRACTORS DECLARATION FLOOR BTU t(J U - OV
1 hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code and my license sin full force and effect
O
License Number L¢ Class - - , V
�369,7A cc
Contractor Date O
❑ I am exempt under Sec _ # s e e e e 8
Plan check fee H
B&P C for this reason PERMIT ISSUING FEES Q I e - 31250
=
Date
Signature TOTAL FEE e • - 3(1506
OWNER BUILDER DECLARATION PIAN CHECK APPLICANT 1 220-85
1 hereby affirm that I am exempt from the Contractor s License ►
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 sole(Section CITY TEL NO
7044 Business and Professions Code) ,
I as owner of the property, am exclusively contracting OWNER NZc,L�LA.t U CLl C1eS,y4q
El
with licensed contractors to construct the project (Sac MAIL58f 4g 30 T C—fl 6644 '31746 -
hon 7044 Business and Professions Code) ADDRE
CONSTRUCTION LENDING AGENCY GTY T G- TEL NO -
I hereby affirm that there Is a construction lending agency for
the performance of the work for which this permit Is Issued - - CONTRACTOR
(Sec 3097, Civ C
Lender's Name NIGULAh— YMLIc .S"i ADDRESS - • - _ r _ _
4L 30 'T�Ar„PI� 8ftrc( ��-. CITY TEL NO
Lenders Address
r--T STATE Uc
I certify that I have read this application and state that the LICENSE tJ0 - - CLASS
above mfornwbon is correct I agree to comply wish all County
ordinances and State jaws relating to building construction
and hereby authorize representatives of this County to enter
upon the a ove mentioned property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
1217 K 12//.-/yS-v —
Stgnoture of Applicant or Agent Date '— '-