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HomeMy Public PortalAbout5722 A-E TEMPLE CITY BLVD_Mechanical__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT -I hereby affirm that I have a certificate of coesent to self insure, or a certiflcdte of Workers Compensation Insgrance ' or a codified copy thereof (Sec 3", Lob c ) 7&A-164C HEATING - VENTILATING - AIR CONDITIONING , • t Policy No C Wtl ompany FA Fz m wi 20 0046 DPW 9/88 1 Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion deportment (PRINT OR TYPE ONLY) ADDRESS Datee MAy�Applicant 1`461TN YAC LOCALITY NO TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST , COMPENSATION INSURANCE CROSS ST ABSORPTION UNIT BTU (This section need not M completed if the sverk imOlvad by DISTRICT NO KQCESIED Illy -the permit Is for one hundred dollar ($100) or less) I certify that In the performance of the work for which this AIR HANDLING UNIT CFM L permit is issued, lihall not employ any person in any manner i t so as to become subject to the Workers Compensation Laws - BOILER BTU APPROVALS &TEX N15ECTO16 WNATURE Dote ' Applicant COMPRESSOR BTU ROUGH NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you,should become subject to the Workers Compensation provisions of the Labor Code you must forth- EVAPORATIVE COOLER VALIDAT149 with comp]y with such provisions or this permit shall be deemIt A - ed revoked FURNACE FAU ITV LICENSED CONTRACTORS DECLARATION FLOOR B •�� - I hereby affirm that I am licensed under provisions of Chapter NIT 9 HEATER SUSPENDED U (commencing with Section 7000)of Division 3 of the Business ' - WALL . and Professions Code and my license Is In full force and effect > ,C License NumbLC —2er C -387s�?7 c Clan d Connector �C1yDote �/d^ O of ' ❑ I am exempt under Sec • to B 8P C for this reason V Plan check fee Date PERMIT ISSUING FEE $ Z SignatureLLL l `—t -�"L TOTAL FEE OWNER-BUILDER D �SION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License Low for the following reason (Section 7031 5, Business and NAME I .- Professions Code) Pi I as owner of the property, or my employees with ADDRESS - ACCT.sr wages os their sole compensation, will do the work and CITY TEL NO the structure n not Intended or offered for sale(Section 3307 133,00 7044 Business and Professions Code) ro _ OWNER I, as owner of the ofl J� L FC , property, am exclusively contracting - - - 1 ITEMS with licensed contractors to construct the project (Sec- MAIL T, / At'E TOTAL yJ C30tion 7044 Business and Professions Code) ADDRESS �5 LA A CONSTRUCTION LENDING AGENCY CITY TEL NO DECK 133,011 r hereby affirm that there is a construction lending agency for , the performance of the work for which this permit is issued CONTRACTOR COOLIA1 �C ANo L Ca ONCE '00 (Sec 3097, Cit C ) ADDRESS LO �/� F Lender s Name f CITY Lp g atc TEL NO - OOOD-0001 5/10/911 Lenders Address 0591 1 AM 8:01 correct certify that I have rood this application to and state that the IXFNSE NO _ S L UZb - above information is coect I agree to comply with all County CLASS C ordinances and State laws relating to budding construction,and hereby authorize representatives of this County to enter ' upon the above mentioned properly for inspection purposes — a SEE REVERSE FOR EXPLANATORY LANGUAGE - 10 Signature of Applkantw Ae nt Dto