HomeMy Public PortalAbout5728 A-E TEMPLE CITY BLVD_Mechanical__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I haver certificate of consent to self
insure, li o l copy the of Workers Compensation Ipsurance,r HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec 38W,,Lab C ) ., . 76AA764C -
PoticyNoll✓I: F— ompony Fal RNo.dT 100046 DPW 9/88 "
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❑ Certified copy is hereby furnished • " I COUNTY OF LOS ANGELES BUILDING AND SAFETY
® Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department (PRIM OR TYPE ONLY) ADDRESS
DateMAY.10 Applicant NAI- LOCALITY
'NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST
(Thli section need swt be w load R the work lntrohsd by AB,SORPiION UNIT Bru DISTRICT NO MED BY
the permB Is for one hundred dollars(1100)or lass) t
I certify that in the performance of the work for which this AIR HANDLING UNIT CFM
permit Is Issued, I shall not employ any person In any manner _ t
sc,a,to become subject to the Workers Compensation Laws BOILER BTU ALS DA 5 SK TURF
I
Dote Applicant t COMPRESSOR BN 2`f-�D 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 VALIDATICIK
with comp)y with such proviaons w this permit shall be deem
ed revoked FURNACE FAU
LICENSED CONTRACTORS DECLARATION FLOOR -
I hereby affirm that'l am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT_
(commenting with Section 7000)of Division 3 of the Business WALL '
and Professions Code,and my license is in full force and effect Y
License Number 15 SZ Lic Class C _w , d
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Contractor � u4TECHAOLc6Ir Da1e y_/0-70 _- m
I am exempt under Sec
P p �� G
Plan check fee L 2"ZD T GT
8 8P C for this reason •• / d
Dae - PERMIT ISSUING FEE $ i
Signature T TOTAL FEE
OWNER-BUILDER DtCLAkATIC# RAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031 S Business and NAME
Professions Code) `r
❑ 1, as owner of the property, or my employees with ADDRESS • O
wages as their sole compensation, will do the work and CITY TEL NO ACCT.`
the structure Is not intended or offered for sole(Section CT
7044, Business and Professions Code) OF�AI LSF 1 M7 133.UO
❑ 1, as owner of the OWNER
property, am exclusively contracting c` �`' ITEM
with licensed contractors to construct the project (Sec yDbRE55 sA Df 1
v
bon 7044, Business and Professions Code) - '
CONSTRUCTION LENDING AGENCY - CITY TEL NO TOTAL 133.00
1 hereby affirm that there Is a construction lending agency for - CHECK 133.00
the performance of the work for which this permit is issued CONTRACTOR
(Sec 3097 Civ C ) .00
�say Leg CnmmurneyADDRESS
Lenders Name r `
171-6hSAD� A W
CITY TEL No OLS-_0001 5/10/90
Lends/a Address A �-p •-s ,''T
1 certify that I have read this application and state that the LICENSE NO C! - UCu55 l: •—�'CJ '0590 1 AM B'DI
above information is correct I agree to comply with all County "
ordinances and State jaws relating to budding construction,
and hereby outhonze representatives of this County to enter
/1 upon the above mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE - T -
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Signature of Applicant gr of Applicant r A��t Date