HomeMy Public PortalAbout5611 TEMPLE CITY BLVD_Mechanical__ WORKERS COMPENSATION DECLARATION 76A384C
I hereby affirm that 1 have a certificate of consent to Self CE B,B (2 Bd) APPLICATION FOR PERMIT
Insure or a certificate of Workers Compensation Insurance or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec 3800 Lab C)
Policy No Company
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county budding inspection
department FOR APPLICANT TO FILL IN BUILDING
Date- Applicant (PRINT OR TYPE ONLY) ADDRESS
CERTIFICATE OI 'EXEMPTION FROM WORK[ RS LOCALIT�ryr�t�. Crry
NO TYPE OF APPLIANCE OR EQUIPMENT FEE '
COMPENSATION INSURANCE NEAREST ,�V� O�� }a,
(This section need not be completed if the work involved ABSORPTION UNIT BTU CROSS 9T O
by the permit t5 for One hundred dollars ($IBD) or less) - DISTRICT NO f PROF �SEDay (,)
I certify that In the performance of the work for which this AIR HANDLING UNIT CFM—
permit
FM permit is issued I shall not employ any person In any manner O
so as to become subject to the Workers Compensation Laws BOILER BTUUr
APPROVALS DATE INSPECTOR SSIGNATURE pyW
Date Applicant COMPRESSOR BTU ROUGH — tGf rn
NOTICE TO APPLICANT If after making this Certificate ofVENTILATION SYSTEM — Z
1 zein peWorkers VENTILATION you should become subject [o the Worke
FINAL
Cumpcnsation provisions of the Labor Cade you must forth
with comply with such provisions or this permit shall be EVAPORATIVECOOLER VALIDATION
deemed revoked FURNACE FAU-- GRAVITY_
LICENSED CONTRACTORS DECLARATION FLOOR BTU
—
I hereby affirm that 1 am licensed under provisions of Chuptcr HEATER SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Bust WALL
effect
and Professions Code and my bcensi, u m toll force and
/ Z 1 "6170
6 j u (7�`�l ,�t� � r
License Number Lie Class—
Contractor—
lass S (�
Contractor Date
I am exempt from the hLensing requirements as 1 am a
licensed architect or a registered professional engmecr Plan check fee 2590' of above
acting in my professional capacity (Section 7051 Bus
mess and Professions Code) PERMIT ISSUING FEE $ Q
Lie or Reg No Date TOTAL FEE
HOME OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
1 hereby affirm that I am exempt from the Contractor's NAME
License Law for the following reason (SIction 7031 5 Busl
}n�e.,s7,s and Professions Code) ADDRESS 9 2.6 6r7 A
I7'I I as owner of the property will do the work and th,, t
T structure Is not Intended or offered for sale (Section CITY TEL NO 8
7044, Business and Professions Code) �
OOWNER E/1r/ r �AIiV`Lyf'r/ 2)�,� 2O .rJO
1 as owner of the property am exclusively contracting
with licensed contractors to construct the project MAIL l2
(Section 7044 Busmess and ProfLSSIORS Code) ADOR�ESSs5a/4' 1, rkfol (J av &o- ;�'� - 2050�
CONSTRUCTION LENDING AGENCY CIrr fewjow CVV TEL NO,;"� -4403 0'609'—.83
1 hereby affirm that there is a construction lending agency CONTRACTOR
for the performance of the work for which this permit is
Issued Sec 3097 Civ C)
Lender s Name ADDRESS
Lender s Address
CITY TEL NO _
I certify that 1 have read this application and state that the STATE LIC
abuse information is cur I 1 agree to comply with all County LICENSE NO CLASS
ordi ces and S[ aws gulatmg Heating Ventilating and
AIr o itionm ;,.d hereb authonre reDresentatnis of Ihu SEL REVLRSt FOR EXPLANATORY LANGUALE
to e"rupon t e above mentiumd property for
pur sef
Signature f Permittee Dete