HomeMy Public PortalAbout5349 TEMPLE CITY BLVD_Mechanical__ WORKER sCOMPENSATION DECLARATION 200M DPW 9f89 APPLICATION FOR PERMIT LIME GREEN
I hereby affirm that I have a certlfictte of consent to self Insure /t
or a certificate of Worker a Compensation Insurance or a certified HEATING-VENTILATING-AIR CONDITIONING rylLlll
copy thereof(Sec 39DO Labb�C)
Policy No 1'r t'Company nTATf-0 1=Ur`J A COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
❑ Cem9ed copy is hereby fumishad
Ea cerafiea copy ra Bled with the county building inapeclla FOR APPLICANT TO FILL IN nooREs�s 5 M C� ✓Q
41 (PRINT OR TYPE ONLY)CCp)) �J LOCALITY wA
Dae CERTIFICATE OF EXEMPTION FROM WORI�R$�" 1�1 NO TYPE OF APPLIANCE OR EQUIPMENT FEES �'`' ,
CROSS ST UL/vG
COMPENSATION INSURANCE ABSORPTION UNIT BTU !Q
(TNe w tlon need not be completed If the work Involved by the ASSESSOR S D pA PARCEL/,510
permit u for one hundred dollaro({100)or leu) AIR HANDLING UNIT,CFM
OdAP B TIO PIOCEeIED ail
I certify that In the performance of the work for which this permit /
IS issued I Shall not employ any person in any manner so as to BOILER BTU
become subject to the Workers Compensation Laws
r COMPRESSOR BN rsrnovua [ATE werEcrce i�
Dab APPIK'ant VENRLATION SYSTEM
NOTICE TO APPLICANT If after making this Certificate of ROUGH 1,70
Exemption you should become Subject to the Workers Compensation EVAPORATIVE COOLER
provisions of the Labor Code you must forthwith comply with such FINALprovision.or this permit Shall be deemed revoked FURNACE FAU_GRAVRY
LICENSED CONTRACTORS DECLARATION FLOOR BTU V L ATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNR_
(commencing with Section 7000)of Division 3 of the Business and WAIL
Professions Code and mylicenseIs in full force and effect
License Number M6 `N ' Lfe
Lc Close tel_ }
'Contrecter G l n1 i 0 N
ASSOCD..-ill2139 (g
❑ I am exempt under sec Plan check fee cc
B eP C for this reason PERMIT ISSUING FEE$ 40 U
Date TOTAL FEE QO d
Slgaary �( AL4-- CIO
r PLAN CHECK APPUCANT >r Z
OWNER BUILDER DECLARATION r
I hereby affirm that I am exempt from the Contractor a License Law NAME I"' N ")� S /Ai Poo G
for the following reason (Section 7031 S Business and Professions r V �LJC.
Code) ADDRESS 3Z IGAN f"FA' GL-+R-1t ACCT.:
❑ I as owner of the property, or my employees with wages LI �' _c
as their sole compensation will do the work and the CRY A.�.A L71A. TEL NO yye I� w07 -!•UV
structure is not intended or offered for sale (Section 7044 - �f, i ITEMS
Business and professions Code) OWNER e �S A1A1✓AT le-Q,0
❑ I as owner of the property am exclusively contracting MAIL _/� )J I UTAS - 25 . 00
with licensed contractors to construct the project (Sec AODBE535`5149? / � Gy �L✓Q
tion 7D44 Business and Professions Code) CHECK, .25.101DCONSTRUCTION LENDING AGENCY CITY G j TEL NO C HM13E .03
hereby anon e o mere lee constructionwhich
this
lending agency issued
for COtTMMR clN-m/V ASSOC ,
the
hereby
affirnce of the work for which this permit a cy for / -
(Sec 3097 Civ C)
ADDRESS /3 54fA!' .4 6LAje, CICO-UOd1 L23/41
Lender s Name
« r _
TY 4e --qD/'4 TEL "O qg,5 /Qyq � 5151 1 AM11:1-5
Lender•Address STATE / Q 0 0/ CLQ n
,I certify that I have read this application and State that the above LICENSE Ivo l0 CJ v '
information is cones I agree to comply,with all County ordinances _ - _ -
satl State law's relating to building construction and hereby authonze I
representatives of this County to enter upon the above-mentioned
property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
E>3NATURE OF APPUCW 54—AUF1R— 1