Loading...
HomeMy Public PortalAbout5615 TEMPLE CITY BLVD_Mechanical__ WORKERS'COMPUNSATIONDECLARATION 76A364C APPLICATION FOR PERMIT 1 hereby affirm that I haI a certificate of consent to self CE 818 (280) insure, acertificate Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING a certified ( d copy thereof(Sec.3800,Lab.C.) Policy No. Company ❑ Certified copy is herehy furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy R filed with the county building inspection FOR APPLICANT TO FILL IN department. BUILDING ..lK Date Applicant (PRINT OR TYPE ONLY) ADDRESS LOCALITY Y CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE a COMPENSATION INSURANCE NEAREST O CROSS ST. f(!r r f I rr U (This section need not be completed If the work involved ABSORPTION UNIT, BTU W by the permit is for one hundred dollars (5100) or less.) DISTRICT No. PP SED ev _J I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM pr y, � LL is permit issued, 1 shall not employ any person in any manner ✓e �� (//r — y so as to become subject to the Workers' Compensation Laws. BOILER, BTU cc Date Applicant APPROVALS DATE INSPECTOR S SIGNATURE < - pD COMPRESSOR, BTU ROUGH O NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM 0- Exemption, you should become subject to the Workers' FINAL Compensation provisions of the Labor Code, you must forth- W with damply with such provisions tir thisEVAPORATIVE COOLER I— permit shall be VALIDATION deemed revoked. - FURNACE: FAU— GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR: BTU I hereby affirm that 1 am licensed under provisions of Chapter HEATER: SUSPENDED UNIT 9 (commencing with Section 7000) of Division 3 of the Busi WALL ness and Professions Code, and my license is in full force and effegF. .6cense Number _ Lic. Class i Contractor Date ❑ I am exempt from the licensing requirements as i am a licensed architect or a registered profinsional engineer Plan cheek fee 25% Of above. acting in my professional capacity (Section 7051. Bus- iness and Professions Code). PERMIT ISSUING FEE $ A, Lia or Reg. No. Date HOME INER-BUILDER DECLARATION PLAN CHECK APPLICANT 1 hereby affirm that 1 am exempt from the Contractor's NAME License Law for the following reason (Section 7031.5, Busi- _ ne' and Professions('ode)'. ADDRESS 1, as owner of the property. wilt do the work and the a e P « a structure is not intended or offered for sale (Section CITY TEL. NO. 7044, Business and Professions Code). OWNER - 'r ❑ 1, as owner of the property, am exclusively contracting I with licensed contractors to construct the project MAIL , « • ' (Section 7044,..Business and Professions Code). ADDRESS ,r _ CITY TEL NO, CONSTRUCTION LENDING AGENCY' 7 y I hereby affirm that there is a construction lending agency -- for the performance of the work for which this permit is CONTRACTOR issued (Sec, 3097.Civ.C.). Lender's Nano, ADDRESS Lender's Address CITY TEL. NO. 1 certify that 1 have read this application and state that the STATE LIC. above information is correct. 1 agree to comply with all County I LICENSE NO. CLASS Ordinances and State law% regulating Heating. Ventilating and Air Clundilioning, and hereby authorive representatives of this 91'P III % I It51' I OR EXPLANATORY LANGUAGE County to enter upon the above-mentioned property for inspection purposes. Signature of Permittee Date i