HomeMy Public PortalAbout5417 TEMPLE CITY BLVD_Mechanical__ W ;bat I have a certificate
DECLARATION 7BA354 DPW a/» 1 APPLICATION FOR PERMIT LIME GREEN
I hereby affirm that I here a cenlficete o1 consent to self insure ]9A9axC i I
or a cdrbncate of Worker a Compensation Insurance or•certified HEATING--VENTILATING-AIR CONDITIONING I h
copy thereof(Sec 3800 Lab C) - LI
Policy No -Company
h COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
Gasified copy Is herebyy hanluml ehe0
❑ CernBed copy m ideit with the county building Inspec1don FOR APPLICANT TO FILL IN - - BADORESS.r I_7 'J-emPG�
depart (PRINT OR TYPE ONLY)
Date _ Applicant � NO TYPE OFAPPLIANCE OR EQUIPMENT PEE LOCALITY
CERTIFICATE OF EXEMPTION OM WORKERS NEAREST
O��v
COMPENSATION INSURANCE ABSORPTION UNITBTU CROS ,
(This section need not be completed If the work invotved by the ASSESSOR ' PAGE
PAf10El -
permit Is for one hundred dollare(1100)or leu) AIR HANDLING UNITCFM MAP
orniecr ra neoccsem m
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 d
become subject to the Workers Compensallon Laws
' COMPRESSOR BTU �
Date Applicantwvnwus a n .uwccmn a 61GNATUM-
VENTILATION SYSTEM
NOTICE TO APPLICANT If alter making this Certificate of ROUGH
Exemption,you Should become subject to the Workers Compensation EVAPORATIVE COOLER
provisions of the Labor Code you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked FURNACE r FAU_ORAVRY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VA ID TION
I hereby affirm that I em licensed under provisions of Chapter 8 � SUSPENDED—UNIT—
(commencing with Section 7000)of Division 3 of the Business and HEAWALL
Professions Code and my license Is In lull force and effect _ 34
License Number Llc Class , 5
Contractor Dale U
❑ I am exempt under sec Plan Check fee _ �J
_ 2
B 6P C for this reason PERMIT ISSUING FEE$ SL 7S 0
oma15
TOTAL FEE 0 Wd
Signature
co
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT . Z
I hereby affirm that I am exempt from the Contractor a License Lew NAME 04 /C7- 1/4 Z_ �-• Z_ 1111.for the following reason (Section 7031 S Business and Professions C
code) IADDRESS S .�j LG—CL Ld AC:T.i
Rel I as owner of the properly or my employees with wages _
as their sole compensation'will do the work and the CITY ��yf�(_� TEL NOffi —/R7
structure to not Intended or offered for Sale (Section 7066 y-.
' Business and Professiorm Code) OWNER �, l 4'Z �/� Z, 1 ITt f I:
® I as owner of the property em exclusively contracting MAIL T:iIAL, 43 - 00,
�T with licensed contractors to construct the project (Sac ADDRESS �A-,e—
Iron 7046 BuRnese and Professions Code) — HEC Y. 4a,i I_I
CONSTRUCTION LENDING AGENCY CITY S .H�'n TEL NO
I hereby affirmrman that there Is a for
ch this
lending a ancy for CONTRACTOR �Oer '
the performance of the work for which lhia perms 4e leauetl ,. -
(Sec 3087 Cry C) `j•?,
ADDRESS 'I'J i lJ l 1/72
Lends°Name {-1
CITY TEL NO 1L; 1:17
Lender s Address
I cenity that I have reed this application and stale that the above uCETENSE NO CLASS
Information o correct I agree to comply with all County ordinance°
and State laws relating to building construction and hereby author¢e - _ -
representatives of this County to enter upon the above ntlon r
property If mspec l pu sse,°1 SEE REVERSE FOR EXPLANATORY LANGUAGE
/ -
jjo
anNA ge'av an _
r