HomeMy Public PortalAbout5126 TEMPLE CITY BLVD_Mechanical__ 1 s
uWOAKERsca"PENSAn°"oonm
snn°" DPW 9189 APPLICATION FOR PERMITLIME GREEN.
I hereby effm.lhet I have a certificate offconsent to cell eure
or a certificate of Worker a Compensation Insurance or a certified - HEATING-VENTILATING-AIR CONDITIONING'
copy thereof(Sec 3800 Lab qqC) - -
Policy Nola9 company GVU D COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
❑ CeruBed copy is hereby furnished
❑ Cer00ed copy U glee with the county udmg Imps tion FOR APPLICANT TO FILL IN - 9uIIDI I h
deperlrtaenl r (PRINT C TYPE ONLY)
LOCALITY
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Acenl NO TYPE OF APPU NCE OR EOUIPMFM FEE L� '
CERTIFICATE OF EXEMPTION FROM WORKERS CROSS T
CROSS m
COMPENSATION INSURANCE _ ABSORPTION UNR BTU
(This action need not be completed If the wort Involved by the _ _ LOPASS BOO _ PAGE
permit Is for one hundred dollen(=100)or Tess) AIR HANDLING Ulm CFM
oasncrao .nods®er
I cenaty that in the performance of the work for which this permit I J ,
Is issued I shall not employ any person In any manner so as to BOILER BTU �DO
become subject to the Workers Comperizatl6p Laws
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Data 3 � (ei 4 Applkanl VENRUTgN SYSTEM
NOTICE TO APPLICANT If after making this CerlifRste of ROUGH
Exemption you should become subject to the Workers'Compensation EVAPORATIVE GOOIER
provisions of the Labor Code you must forthwith comply with such FINAL
provisions or thio permit shall be deemed revoked FURNACE FAU_
_ LICENSED CONTACTORS DECLARATION FLOOR STU X/ 11 VALIDATION
I hereby affirm that I em licensed under provisions of Chapter g HEATER SUSPENDED—UNIT—
(commencing
USPENDED UNIT_(commencing with Section 7000) of Dlvislon 3 of the Business and WAIL
Profession&Code and my license is in full face and effect
L icenee Number LIC Clam._
Contracts Lr,J vq(p 010. v (L
ElI am exempt unser Bac Plan check fee ACCT.i U
3307 06.65c x
B aP C for this reason PERMIT ISSUING FEE$ 1 ITEMS O
, ` Data✓ TOTAL FEE p TOTAL 106-65 w
vmOWNER BUILDER DECLARATION PLAN CHECK APPLICANT _ CHECK 106.65 Z
I hereby affirm that I am exempt from the Contractor a License Law NAME , `jE ,O[I
for the following reason(Section 7031 5 Business and Profaseions
Code) ADDRESS
❑ I as owner of the property or my employees with wages VOOV—DI�V1 �� 6�9J
ee'their sole compensation will do the work and the CITY TEL NO
structure Is not intended'or offered for sale (Section 7044 1 AMii:�'�
Business and Professions Code)
❑ I as owner of the property em exclusively contracting MAIL
with licensed contractors to construct the project (Sec ADDRESS '
tion 7044 Business and Professions Code) CRY r TEL NO —0,
CONSTRUCTION LENDING AGENCY r
I hereby affirm that there Is a construction lending agency for
the performance of the work for which this permit s ieeue _
(Sec 3087 CN C) V�
ADDRESS
Lender a Name
CITY TEL ND r 0
Lendw a Address STATE LIC
I certify that I have reed this application and state that the above uCENSE NO CUSS
information rs correct I agree to comply with all County ordinances
and State laws,relating to building construction and hereby authorize
repro tentatwes of that County to enter upon the above mentioned
property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
r1A a APPLGANI AG '