HomeMy Public PortalAbout5334 TEMPLE CITY BLVD_Mechanical__ WORKERS COMPENSATION DECLARATION I APPLICATION FOR PERMIT
'I hereby offirm lha I have a certificate of consent to self
insure,.'- a certificate of Workers Compensation Insurance, HEATING • VENTILATING • AIR CONDITIONING
or a certified copy thereof (Sec 3809 Lab C 1 70YD-0404e046
• � DPW 9/88 .
Policy No Company —
Certified copy m hereby furnished
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
t tion'department (PRINT OR TYPE ONLY) ADDRESS I�jCJ
' Date 4 Applicant LOCALITY
` NO TYPE OF APPLIANCE OR EQUIPMENT FEE l�
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST L,✓`
COMPENSATION INSURANCE CROSS ST O C
1
h 1 (This section need not be completed if the work Inrolwd by ABSORPTION UNIT BTU DISTRICT `ROC BY
the permit Is for one hundred dollars ($100)or leu)
I certify thot In the perfofmance of'the work for which this AIR HANDLING UNIT CFM
Permit is Issued, I shall not employ any person In any manner
Sa OS f0 become subject.Ito the Workers Compensation Laws BAILER BTU-
• ' APPROVALS DATE INSPECTORS SIGNATURE
1+� Dote I Appbcant
COMPRESSOR BTU' — ON 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 _ I ATIO _
with comply with such provisions or this permit shall be deem
'- ed revoked I FURNACE FAU ' GRAVITY 6
LICENSED CONTRACTORS DECLARATION BOOR BTU
' I hereby affirm that I am licensed under provisions of Chapter 9HEATER SUSPENDED UNIT—
tiDivision
+ � SUSPENDED—UNIT—
(commencing with Section 7000)of Dlsion 3 of the Business � � WALL
and Professom Cade,and my license is in full face and effect - OCL (� }
0 y
Ucense Number Llc Class - O
► Ld
oe
Contractor Date O
_ V
am exempt unclar Sec Plan check fee
W
B 8P C for this reason PERMIT ISSUING FEE $ Z
Date
TOTAL OTAL 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
Professions Code)
J ADDRESS^-
14 I as owner of the property or my employees with
wages as their sole compensation, will do the work andACCT t
the structure Is not Intended or offered for sale(Section
CITY -•—.._ TEL NO T
7044, Business and Professions Code) OWNER -:307 52.1-10
F]i I os owner of the property am exclusively contracting
T with licensed contractors, to construct the project (Sec MAIL 1 ITEt1J
hon 7044, Business and Professions Code) ADDRESS TOTAL �J ��
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for Clir TEL NO WCK Ur','.((,
the performance of the work for which this permit Is Issued CONTRACTOR
(Sec 3097, Civ C ) t. ] .GO
ADDRESS
Lender's Name ' r ' •' ' �
Lenders Address ~ CITY TEL NO rO�[��o-OMI `313/Gill I
STATE LLC ]TaCr `1 An 9:02
I certify for I have rood this gree Cohort and state that the LICENSE NO CLASS
above information is correct I agree to comply with all County
ordinances and State laws relating to building construction, +
aild hereby authorize representatives of this County to enter
u n the above-menho property for inspection purposes
SEE RE VERSE FOR EXPLANATORY LANGUAGE
SI
noturff Appkont or Date ms