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