HomeMy Public PortalAbout5450 TEMPLE CITY BLVD_Mechanical__ fflWOthatISCOMPENSATION DECLARATION arm APPLICATION FOR PERMIT LIME GREEN
I hereby errp that have a certificate of consent to Bell insure
or a certalcete,of Worker a Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec 3800 Lob C)
No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDIEl NG AND SAFETY DIV
Certified copy Is hereby furnished
C tmropy In filed with the uwnry anldap Inspe,�ilpri FOR APPLICANT TIN INO
(PRINT
R � ONLY) ADD�g / D
D,./—/40 -96 App NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY G
CERTIFICATE OF EXEMPTION FROM WORMERS NEAREST
COMPENSATION INSURANCE CR09S
ABSORPTION UNIT BN p
=(TMs"often for naetl not be completed N the rock Involnd by the ASSESSOR O�� PAGea 5 PARCEL�'7S
permit la for ons hundred dollars(1100)or bo) NR HANDLING UNIT CFM
I certify that in the performance of the work for which this pwmit
Is issued I shall not employ any person In any manner so as to BOILER BTU „y t
become subject to the Workers Compensation Laws p LO
I COMPRESSOR BTU lf�BbO fI .
' IPna)vxs MTE McPE[:IpIB W' MTalal
Data Apphcent VENTILATION SYSTEM
NOTICE TO APPLICANT If alter making this Certificate of ROUGH
Exemption you shwld become subject to the Workers Compensation
provisions of the Labor Code you must forthwith comply with such EVAPORATIVE COOLER FINAL
provisions or this permit shall be deemed revoked FURNACE FAU_ORAVRV
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter S SUSPENDED UNIT_ _
(commencing with Section 7000) of Division 3 of the'Busmeas and NEATER WALL
Professions Code and
�mmyyllicense Is In full force and effect
Ucenne Number7(O6 /7 9Llp Class L, o
c maYfaf�l•1� 7Wme6' a
30-96 $
Plan check fee
❑ 1 am exempt under Sec $ Q
B aP c for this reason PERMIT ISSUING FEE$ D O
DemACCT.'. c�i
TOTAL FEE a. 3303 122.50 a
Signature Eye co
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ITG11U Z
I hereby affirm that I am exempt from the Contractor a License Law NAME , TOTAL 122.50
for the following reason (Section 7031 5 Business and Professions
Code) ADDS' CHECK 122.50
I as owner of the property or my employees with wages CHANGE
as their sole compensation will do the work and the CT' TEL NO i
structure is not Intended or offered for sale (Section 7044 '
Business and Professions Code) OWNER '
❑ I as owner of the property am exclusively contracting001 1/16/96
with licensed contractors to construct the project (Sec CRESS 4268 1 AM 8:53
tion 7044 Buslness and Professions Cade) on
CONSTRUCTION LENDING AGENCY CITY - TEL NO Q 3
I hereby affirm that there is a construction lending agency for CONTRACT
y
the performance of the work for which this permit Is Issued
IS 3007 Civ C) _
ADDRESS
Lenders Name
m � TEL No
Lenders AddreaaSTE
/ / _
I certify that I have read this application and state that the above LICENSE NO(� p CABs G y b
information Is conect I agree to comply with all County ordinances
and State laws relating to building cormtruclgn and hereby authorize
repreeantatwes of this County to enter upon the above mentioned
props y or in action purpos a BEE REVERSE FOR EXPLANATORY LANGUAGE
PPLCANT ApEM MTE - -