Loading...
HomeMy Public PortalAbout5504 TEMPLE CITY BLVD_Mechanical__ WORKER S COMPENSATION DECLARATION 2D-O cOPWSfaB 1 I•hereby affirm that I have a certificate of consent to sell insure APPLICATION FOR PERMIT LIME GREEN or a certificate of Worker a Compensation Insurance or a certified HEATING-VENTILATING-AIR CONDITIONING copy Tereol(Sac 3800 Lab C) , Poky No company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV ❑ Candied copy is hereby furnished I I ` ❑ g:; copy Is filed with the county,wllang Inspection FOR APPLICANT TO FILL IN MDRdE�A��/ tlepMlmenI (PRINT OR TYPE ONLY) L 1 Date Appllranl NO TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERSNEAREST �/I// CROSS ST 0 COMPENSATION INSURANCE ABSORPTION UNIT BTU ^'/ (This section need not be casplst id If the work Involved by the MAPk1AP SOOK S PAG/011 PARCEL 46/3 permit Is lair one hundred dollars(8100)or leu) NR HANDLING UNIT CFM pe1WCT Iq EL5E0 aY I candy that In the performance of the work for which this permit Is issued I shell not employ any person in any manner ao as to 0 become subject to the Workers Compensation Laws COMPRESSOR BTU 7 000 NTnaiN4 oIre �s®rnnxF Data Applicant VENTILATION SYSTEM NOTICE TO APPLICANT If after making this Certificate of _ ROUGH `Exemption you should become subject to the Workers Campeneahon EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such I FINAL provislons or this permit shell be deemed revoked FURNACE FAU GRAVrTY - - LICENSED CONTRACTORS DECLARATION FLOOR BTU OU t VALIDATION I hereby affirm that I em licensed under provisions of Chapter B SUSPENDED UNIT (commencing with Section 7000)of Division 3 o1 the Bualnens and HEATER WALL Professions Code and my license is In full face and effect / � e0 License Number Ldc Cleo 49 t � � ap Contrera Date U ❑ 2 I aril exempt under Sec Plan check fee B 8P C to this reascn PERMIT ISSUING FEES 00 0— DaaTOTAL FEE 0� III Slgnaure IL Coll OWNER BUILDER DECLARATION PLAN APPLICANTZ I hereby affirm that I am exempt from the Contractor a License Law NAME0&1 �J Y n./ �— ► , for the following reason (Section 7031 S Business and Professionsllpqcks� ADDRESS v I as owner of the property, or my employees with wages ��!�� as their sole compensation will do the work and the CITY TEL NO �i7 .�IL structure Is not Intended or offered for sale (Section 7044 1 ITEM: Business and Professions Code) OWNER j ❑ I as owner of the property am exclusively contracting MAI ' TOTAL 53 . 00 ' with licensed contractors to construct the project (Sec ADDRESSQh-1 /r CAM 53.01, tion 7044 Business and Professions Code) NO CONSTRUCTION LENDING AGENCY CITY TEL CHAth .C11 I hereby affirm e o there lee constructionwhi this sperlending agency for .TOR the performance of the work for which ihle permit le issuedCONTRACTOR' (Sec 3087 CM C) ` ADDRESS 0000-0601 6i 113,'71 Lender a Name CITY TEL NO 7411 1 Am 8:Y. Lenders Address STATE LIC I cartlty,that I have reed this application and state that the above LICENSE NO Cuss Information is coned I agree to comply with all County ordmances - end State have relating to building construction,and hereby authorize rjfmfserftabvaa of unty to enter upon the above-mentioned prop d ertna ctl I purposes SEE REVERSE FOR EXPLANATORY LANGUAGE OF APP00AW ORAGENT M/ t