HomeMy Public PortalAbout4932 TEMPLE CITY BLVD_Mechanical__ WORKER
tI have PENSATION Df consent
YO-0OOe DPW e1e9 APPLICATION FOR PERMIT LIME GREEN
7aV6aC
I hereby eflu61 that I have a certificate of consent to self Insure
or a certificate of Worker a Compensation Insurance or a certified HEATING-VENTILATING-AIR CONDITIONING
copy-thereof(Sec 3800 Lab C) `
Policy No company COUNTY OF LOS ANGELES - DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
❑ Certified copy is hereby furnished
❑' `Carolled copy Is glad wnh the county building inspection FOR APPLICANT TO FILL IN ADDRESS r-F 9`dQ TEMPLE C 1 Y Y $0, C)
department , (PRINT OR TYPE ONLY)
Det, Applicant NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY 4 EM P LE= C 1 TY, C A 9 080
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS CROSS ST
_ , f_, COMPENSATION INSURANCE ABSORPTION UNIT BTU
(This section need not be completed N the work Involved by the - _ ASSESSOR
MAP BOOK PAGE PARCEL _
permit Is for ono hundred dollars(1100)m Nu) NR HANDLING UNIT CFM CGmc T aPocF9em of
I certlty,that In the performance of the work for which this permit
Is Issued I shall not employ any person In any manner to as to BOILER BTU
become subled to the Workers Compensation Laws
COMPRESSOR BTU
Date Applicant svwavN.e are eoannAal
VENTILATION SYSTEM
NOTICE TO APPLICANT If after making this Cerllllcete of ROUGH
Exemption you should become subject to the Workers Compensation EVAPORATIVE COOLER
provisions of the Labor Code you must forthwith comply with ouch FINAL
provmlonn or this permit shell be domed revoked FURNACE FAU_GRAVITY
, I LICENSED CONTRACTORA DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I em licensed under provisions of Chapter 9 NEATER SUSPEN UN1T
(commencing with Section 7000)of Division 3 of the Business and yyALL
Professions Code and my license Is In full force and effect
c , r r
License Number LIc Clens
Contractor Date O
❑ I am exempt ander sac Plan check fee V
Q
B aP C for this reason PERMIT ISSUING FEE= 1'4- O
Data TOTAL FEE W
Signature d
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT Z
Z
I hereby affirm that I em exempt from the Contractor a License Lew NAME � r
for the following reason(Section 7031 B Business and Professions �1'(T•T
Code) ADDRESS '
❑ I as owner of the property or my employees with wages ,31[17 y'-•-i-I
as their sole compensation will do the work and the CITY TEL NO j ! ,-
structure 19 not intended or offered for sale (Section 7044
Business and Professions Code) OWNER J L19 o N 'Leo NG 4e _ 00
® S TJi,iL
I as owner of the property em exclusively contracting T
with licensed contractors to construct the project (Sec AOp�ESS 932 -tE�IP LQ C 1 D BLV
don 70" Business and Professions Code) _lI
CONSTRUCTION LENDING AGENCY CRY Tt M P L G CIT`P Tse ND z8'7-Z 3 63
hereby affirm that there Is a construction lending agency for CONTRACTOR
the performance of the work for which this permit fe Issued
(Sec 3097 Civ C) Ia'I,IJ—Q17Q'� i
ADDRESS
Lender a Name
Cin TEL NO
Lender s Address
I certify that I have reed this application and state that the above SLI ENSE NO CCLiASS -
mformebom is owed I agree to ccxmpy with all County ordinances
and State laws reletmq to bu1ldWng conatiuctlon and hereby authorize
representatwee of this County to enter upon the above mentioned
property for Inspection urpoaee SEE REVERSE FOR EXPLANATORY LANGUAGE
waATuaE ac APPIS.ANr aR Roam i 1 CATE '