HomeMy Public PortalAbout5319 TEMPLE CITY BLVD_Mechanical__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm 4hatll I hava a'certificate of conlenl to self
orsarcertir a tif certified cc�000�pppp�y,,,,����tha�r.e.esfof-(Sece 3800�0e�Lab C ,on IAyn..�s-urance, 76A.1W HEATING - VENTILATING - AIR CONDITIONING
20 Policy No Company 4"Z
OOG6 DPW 9/BB '
❑ Certified copy i hereby furnis ed COUNTY OF LOS ANGELES BUILDING AND SAFETY
n ❑ Certified copy`is filed with the county building inspec- FOR APPLICANT TO FILL IN BU DING
tion department ADDRESS'S3I T{�! C1 ��L✓O
r (PRIM OR TYPE ONLY)
DateApplicant LOCALITY yGt7 G/7
TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE - CROSS ST y
ABSORPTION UNIT BN
_ (This stolon need not be
wmPlMad If fisc teork Involved by oaTaicr NO ('/ sr
Ilse certify
th Is for one hundred dollen ({loo) or lett) _ AIR HANDLING UNIT CFM Off-
so
J�
- I certify thou in the performance of the work for ywhich
ma the (((/// l I
permit is issued, I shall not employ any person in any manner
so as to become sublect to the Workers Compensation Laws BOILER BTU '/� APPROVALS INR oR s s n1RE
Date 'Applicant
COMPRESSOR BTU 14 0,02"oa ROUGH
i NOTICE TO APPLICANT If, after makingthis Certificate of _ _
VENTILATION SYSTEM FINAL
Exemption you should become subject to the Worker
Compensation provisions of the Labor Code you must forth- EVAPORATIVE COOLER A D TI
with comply with wch provisions or this permit shall be deem- _
ed revoked I _ FURNACE FAU GRAVITY
i LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business WALE
and Professions Code,and my license is in full force and effect
o 0a r - - 00 >
License Number s� Lic Class a d D , d,
U
Contract =te $ D oc
❑ I am exempt under•Sec '
Plan check fee ty
• B 8P C for the reason 0 d
Date PERMIT ISSUING FEES Z
Signature TOTAL FEE
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT -
I hereby affirm that I am exempt from the Contractor's License
Low for the following reason (Section 7031 5, Business and NAME - Poo..
,
Professions Code)
❑ I, as owner of the property, ADDRESS' sg
p party, or my employees with i
wages as their sole compensation,will do the work and CITY---- TEL NO ACCT.T
the structure is not intended or offered for sale(Section (I
7044 Busmew and Professions Code) ' 3307 59.0.
❑ I, m owner of the o OWNER Q 5
ra perry, am exclusively contracting
(Sec-
1 ITEM
sash licensed contractor to construct the protect (Sec- MAIL c `
tion 7040, Business and Professions Code) ADDRESS 9 TOTAL, .!. 9. 00
CONSTRUCTION LENDING AGENCY --++
I hereby affirm that there is a construction lending agency for CITY d '� TEL NO Y�D CHECK 59.W
the performance of the work for which this permit s issued CONTRACTOR
(Sec 3097 civ C 00 7-4& 440IZ664a OO
ADDRESS __
Atr
Lender's Nome •� r
Lender's Address CITY �� ��� TEL NO l/ _/�,( _ - OM-OW 1 3/ 9/90
I certify that I have read the applicationand state that the LICE NO 3Q TE LIMO SS C 6
r �-• 94188 -1 AM8`06
above information is correct I agree to comply with all County
ordinances and State laws relating to building constructionand hereby authorize representatives of this County to enter '
upon the above mentioned property for inspection p rposes' - - - - - - -
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or A964t Dote `