HomeMy Public PortalAbout5313 TEMPLE CITY BLVD_Mechanical__ WORKERS COMPENSATION DECIARATION
herehy aim that I have a certificate of consent to ,elf APPLICATION FOR PERMIT
insure or a certificate of Workers Compensation InsuranceHEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec 3800, Lob C ) CE 81 C
CE BIB(REV 10/8I)
P❑oliicy No Company
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
r ❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING —C31-3TEM�i�GTy BGI�Q
tion department (PRINT OR TYPE ONLY) ADDRESS
' Date Applicant LOCALITY `? fopie 1104Ty
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST OL'✓/_
COMPENSATION INSURANCE CROSS S7 G
(Thls soctfon mod not be completed if the work involved by ABSORPTION UNIT'BTU DISTRICT No �(79D Y
the porn tt Is for a"hundred dollars ($100)or lou )
r AIR HANDLING UNIT CFM Q �y
I certify that in the performance of the work for which this c (/
permit Is issued, 1 shall not employ any person in any manner
so,as to become subject to the Workers Compensation Laws BOILER BTU ,,11 APPROVALS DATE ' INSPE S SIGNATURE
Date Applicant COMPRESSOR BTU I v 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 VALIDATIOK
with comply with such provisions or this permit shall be
deemed revoked - FURNACE FAU_G VIN
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT=
(commencing with Section 7000) of Drvnion 3 of the Business WALL
and Professions Code,and my license is in full force and effect Z d
Q` O
License Number Lic Clair - Poo. 1J
9 V
Contractor ' Dote O
❑ I am exempt-under Sec I # • s s s s 8 U
Plan check fee • • 53 I 2 5
B&P C for this reason 2
PERMIT ISSUING FEE $ U
Date _ TOTAL FEE • • • 5325'0
Signature /s
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT ' DO. 33-0 2
hereby affirm that I g r exempt from the Contractors ss nd I, ,
Law for the following reason (Section 7031 5 Business and NAME mss' A V!v
,p�rjo(�essions Code) -
OAJA
Ii1 I as owner of the property or my employees with ACES > a 3 G /P F�//
��" wages ct thea sole compensation will f o the work and -jw1*10(i✓ 1
the structure n not intended or offered for sale(Section CITY G�'I � 1 TEL NO e2B6 Zf�+
7044 Business and Professions Code)
OWNER
I as owner of the property am exclusively contracting
with licensed contractors to construct the project (Sec MAIL
ADDRESS
tion 7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY CITY TEL NO
hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is-issued - CONTRACTORS
(Sec 3097 Civ C )
ADDRESS
,Lender s Name
CITY , TEL NO
Lendei s Address
I certify that I have read this application and state that the LICENSE NO CLASS
above information is correct I agree to comply with all County '
ordinances on State jaws relating to building construction,
and hereby horde representatives of this County to enter -
n t mention rop for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature Of APPhcant Or ent Dore - - - - - ,-