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Home My Public Portal About5411 TEMPLE CITY BLVD_Mechanical__ WORKERS COMPENSATION DECLARATION •riAPPLICATION FOR PERMIT Iereby bffirm that I have o certificate of consent to self insure or a certificate of Workers'Compensation Insurance or a certified copy thereof (Sec 3000 Lab C ) 76A3 _ HEATING - VENTILATING - AIR CONDITIONING CE 818R EV 10/81)- Ory No Company LT.` t"1 ii Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county building mspec-- - BUILDING eon department ' FOR APPLICANT TO FILL IN ADDRESS ApApplicantApplicanta-�''� Dote ��' (PRINT OR TYPE ONLY) .JJ��UJ• $ � LOCALITY // F NO TYPE OF APPLIANCE OR EQUIPMENT FEE � CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST O L COMPENSATION INSURANCE CROSS S7 It section need net be cam ABSORPTION UNIT BTU (Tb plefed H The work Imrolred b1' DISTRICT rJ0 ai-li the permit Is for one hundred dollars ($100)or less ) AIR HANDLING UNIT CFM T I certify that in the performance of the work for which this hL r U 8 r r permit is Issued I shall not employ any person in any manner ✓/ so as to become subject to the Workers Compensation Laws BOILER BTU AF ALS DATE INSK0CdR s sic URE Date Applicant COMPRESSOR BTU Q ROUGHlin 1 0 111 NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINALf Exemption you should become sublet; to the Workers n 14 Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VALIDATI N with comply with such provisions or this Permit shall be deemed revoked / FURNACE FAU ITV D G LICENSED CONTRACTORS DECLARATION ` FLOOR B , I hereby affirm that I am licensed under provisions of Chapteri? HEATER SUSPENDED UNIT_ (commencing with Section 7000) of Division 3 of the Business WALL and Professwns Code and my license is in full force�/� and� effect 11111. License Number 30 a 8(05 Lic Classi� _ ,G v Contractor`'1-� S ^ to V - 00, ❑ I am exempt under Sec su Plan check fee d 8 8P C for this reason us PERMIT ISSUING FEE $ d = Date Signature TOTAL FEE OWNER BUILDER DECLARATION PLAN CHECK APPLICANT35 I hereby affirm that I am exempt from the Contractor s License , Law for the following reason (Section 7031 5 Business and NAME Professions Code) ❑ I as owner of the property or my employees with ADDRESS wages as their sole compensation will clothe work and CITY TEL NO 4 - the structure is not intended or offered far sole(Section 7044 Business and Professions Code) OWNER ❑ I as owner of the property co exclusively contracting ,MAIL - _ ,Q/ - ;92355A with 044 Bu contractors Professions construct the project (Sec ADDRE W eon 7044 STRU TI Ond ENDIGACode) # • 8 CONSTRUCTION LENDING AGENCY City P/h TEL �_ So D hereby affirm that there is a construction lending agency for ► I • * 3550 the performance of the work for which this permit is issued CONTRACTOR - (Sec 3097 Civ C ) ��1 CL(.(A/L ADDRESS Q�. _ - • * - 3a503 Lenders Nome CITY TEL NO 9 627-85 + _ Lender s Address STATEp ' I certify that I have read this application and state that the LICENSE NO V _ CW55. above information is correct I agree to comply with all County ordinances and State jaws relating ;o building construction and hereby authorize representatives of this County to enter upon the above mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE_ Signulure of Applicant or Agent