HomeMy Public PortalAbout5466 TEMPLE CITY BLVD_Mechanical__ WORKkRS' COMPENSATION DECLARATION i
hereby affirm that I hove q certificate of consent to ,elf APPLICATION FOR PERMIT
insure oro certificate of Workers Com'aensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
7M364C r
cr a certified copy thereof (Sec 3800, Lob C) -
1PODb DPW 9/8B
Policy No Company `
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building Inspec- BUILDING
tion department ` FOR APPLICANT TO FILL IN ADDRESS S y
(PRINT OR TYPE ONLY)
' Date Applicant - LOCALITY
t NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST ,
COMPENSATION INSURANCE CROSS ST
T ABSORPTION UNIT BN -
(Thb section need not be comyleMd B fit work Imohed by asTRicr`K PRocEs s
the permit is for one hundred dollars ({100)ar`leu) _ _
I certify that in the performance of the work for which this AIR HANDLING UNIT CFM'
perm I is issued I shall not employ any person in any manner
so as to become subject to the Woke'rsnCompensation� 4./Laws BOILER BTU gpPROVALS TE OR s SIi3NATURE
Date_� J () Appl=nt�r:Y ' --'_ f COMPRESSOR BTU 1 Of 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 ,
with compI with such provisions or this permit shall be deem
ed revoked I FURNACE FAU_GRAVITY
��
LICENSED CONTRACTORS DECLARATION FLOOR BTU
hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect
tY
License Number Z Z Lic Closs�J a O J� poll
6
o ll lio
O
Contractor 7 Date 2'� r 90 W
❑ I am exempt under Sec - G
1 .1Plan check fee W
B&P C for this reason H
Date PERMIT ISSUING FEE $ D Z
Signature TOTAL FEE
OWNER-BUILDER DECLARATION RAN CHECK APPLICANT
I hereby affirm that I am exempt from the Connector s License ,
Low for the following reason (Section 7031 5 Business and NAME ' ' O
Professions Code)
1 as owner of the property, or my employees with ADDRESS-
wages as then sole compensation,will do the work and CITU . TEl NO 7 J.CR+
the structure is not intended cr offered for sale(Section _
7044, Business and Professions Code) 1 IT
I, as owner of the property, OWNER
pr pe ry, am exclusively contracting
with licensed contractors to construct the project (Sec MAIL _ I TOTAL 553 r d❑
tion 70" Business and Professions Cade) ADDRESS � C tl-
CONSTRUCTION LENDING AGENCY cl CHEGK 53.03
I hereby affirm that there is a construction lending agency forTy-
the performance of the work for which this permit o issued CONTRACTOR ►
(Sec 3097, Civ C )
ADDRESS ,
Lender s Nome - - ` 13000-17001 2/15/913
aTY E, rEL _ y3
Lender's Address _ _ _ 9965 , _ 1 AI 942
I certify that I have read this application and state that the U�NSE No_.? Z LIC
'
above information a correct I agree to comply with all County
ordinances and State laws relating to budding construction, r -
and hereby authorize representatives of this County to enter
iuurppn000n the6 a mentioned prppemy for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE ,
Signature of Applicant or Agent Dote i
mt