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