Loading...
HomeMy Public PortalAbout5471 TEMPLE CITY BLVD_Mechanical__ WORKER Save ac certificate DECLARATION z0004e DPW a,BB APPLICATION FOR PERMIT LIME GREEN 7 A36/C I hereby eihrm shell have a cenlhcate of consent to self insure m a certificate of,Worker s Compensation Insurance or a certifies HEATING-VENTILATING-AIR CONDITIONING COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV Confined copy is hereby furmahed Certified ropy is flied with the county building inspection FOR APPLICANT TO FILL IN �,yp pE1S*S .y department (PRINT OR TYPE ONLY) �J DateLOCALITY Applicant NO TYPE OF APPLIANCE OR EQUIPMENTFEE CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST CROSS ST COMPENSATION INSURANCE ABSORPTION UNIT BTU _ (Thin eeetlon need not be completed N Me work involved by the ASSESSOR PAGE PARCEL permit is for one hundred dollars(3100)or letw) AIR HANDLING UNIT CFM ossmcr nc vaacseeeo BY , I certify that in the performance a1 the work for which this permit leetl I shall not employ any person In any manner so as to BOILER BTU become subject to the Workers Compensation Laws • COMPRESSOR BTU DU O Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT If atter 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 shell be deemed revoked FURNACE FAU_GRA 6/ 'Z7 61 LICENSED CONTRACTORS DECLARATION / FLOOR BTU 0 VALIDATION I hereby affirm that I em licensed under provisions of Chapter 8 SUSPENDED UNTT_ (commencing with Section 7000) of Division 3 of the Business and HEATER WALL Professions Code end my license is In full force and effect 6�y 76 S / a Licensee Numb tic Clew 'Z' 7 7�eti 1 ,�/ � 8 a contra 444— l�T^Y#.. 'r'8 —/ - 9� ACCT.: o ❑ I arra exempt ander Sao Plan check fee 3303 114,10 cc B aP C for this reason PERMIT ISSUING FEE i L) 1 ITEMS 0 Date TOTAL FEE / TOTAL 114 - 10 W Sana lire0. CIECK 114.10 V) OWNER BUILDER DECLARATION PLAN CHECK APPLICANT _ . Z I hereby affirm that I am exempt from the Contractor a License Lew NAME ► 00 for the following reason (Section 7031 5 Business and Professions Code) - ADDRESS I as owner of the property, or my employees with wages 0000-0001 4/ 8/96 as their sole compensation will do the work and the CT' TEL NO 1 1 AM 7:55structure is not Intended or offered for sale (Section 7044 sIS575 Business and Professions Code) OWNER 1 as owner of the property em exclusively contracting with licensed contractors to construct the project (Sec MAIL _ ~ iron 7044 Business and Professions Code) CONSTRUCTION LENDING AGENCY CITY TEL N <J '�12. I hereby affirm that there Is a construction lending agency for CONTRACT I perform ante of the work for which ihse'parmit la issued (Sec 3087 Civ C) ADDRESS01 XO w.Ali u Lenders Name 1 44f/O^'���/ - crg,1,1, TEL No�g''•j.�l D'/« . Lender s Address ATE _ I certify that I have reed this application and state that the above UCENSE NO 9 CLASS C, ;Z 0 information Is correct I agree to comply with an County ordmances and State laws relating to building construction,and hereby authonze , representatives of this County to enter upon the abovementioned props f r inspection pu,oe � BEE REVERSE FOR EXPLANATORY LANGUAGE o ,rwUCANro Aatxr ore