HomeMy Public PortalAbout5017 TEMPLE CITY BLVD_Mechanical__ N&ER kCOMPENSAicate of consent to DPW a/� APPLICATION FOR PERMIT LIME GREEN
1040,16
I tssnbp enfFm that I have a certificate of consent (a self maria
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
❑ Certdletl ry BUILDING
copy w flied wnh the coon builds inspection FOR APPLICANT TO FILL IN ADORES$ O 7 71111P(,� C( % LI7V,
tleparlmeM , , (PRINT OR TYPE ONLY)
• Dale t T Applicant NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF ExEMPTION f ROM WORKERS NEAREST
CROSS ST
COMPENSATION INSURANCE ABSORPTION UNIT BTU
_ ASSESSOR
(This section need not be completed If the work Involved by the MAP BOOK PAGE PARCEL
permit Is for one hundred dollars(*100)or less) AIR HANDLING UNIT CFM
omxr ra rmcessm sr
I certify that in the performance of the work for which this permit _
is Issued I shall not employ any person in any manner so no to BOILER BTU
become subject to the Workers Compensation Laws - p '
C( /9 q /Apple ar; i COMPRESSOR BTU
Dale 6 00� G O
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VENnLAT10N SYSTEM
NOTICE TO APPLICANT If after making this Certificate of ROUGH
Exemption you should become subtest to the Workers Compensation EVAPORATIVE COOLER
provisions of the Labor Code you must forthwith comply with such FINAL
provisions or this permit shell be deemed revoked
UCENSED CONTRACTORS DECLARATION FLOOR FURNACE FAU BTU Y VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT_
(commencing with Section 7000)of Division 3 of the Business and HEATER WALL
Professions Cade and my license Is in full force and effect
License Number Llc Clam
CL
Contractor Date $ O
❑ 1 em exempt under Sec Plan check fee ACCT.i U
B 8P C for dns roenon PERMIT ISSUING FEES3 '90 O
Date TOTAL FEE 1 ITEMS (~,)
Signature PLAN CHECK APPUCANT D TOTAL 53- 90 i N
OWNER BUILDER DECLARATION ( ,,.,.[, 53.90 Z
1 hereby affirm that I am exempt from the Contractor a License Lew NAME ► 7y�Ay� 00r1f1
for the following reason (Section 7031 5 Business and Professions lflnl\VG .
Code) ` ADDRESS -
1 as owner of the property or my employees with wages nnnn__nnn
as their sole compensation will do the work and the CRY TEL NO 0000-0001 4/19/96
structure Is not Intended or offered for sale (Section 70115974 1 AM 919
iA' M
Business and Professions Code) OMEA V
❑ I as owner of the property am exclusively contracting _
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with licensed contractors to construct the protect (Sec ADDRESS Q,C- /CLQ i l9Tr Q'e
tion 7041 Business and Professions Code) I ),
CONSTRUCTION LENDING AGENCY c" Wr CO1111,4- TEL NO pe gr9 O ,
I hereby affirm that there Is a construction lending agency for ,
the performance of the work for which this permit la Issued CONTRACTOR L'vfujEJ _
(Sec 3087 Civ C)
ADDRESS
Lenders Name
CITY TEL NO
Lender a Address STATE - UC -
I certify that I have reed this application and state that the above LICENSE NO CLASS
information is correct I agree to ccniply with all County ordinances ,
and Slate laws retailing to building construction and hereby authorize
representatives of this County to enter upon the above mentioned
property for inspection purposes SEE REVERSE FOR E�PLANATORY LANGUAGE
BgNA OF De M MTE