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HomeMy Public PortalAbout5729 TEMPLE CITY BLVD_Mechanical__ I � i ' WORKERS'COMPENSATION DECLARATION CEA'818(2.601 6=a I�����D®I�1 ®� u�ll u I hereby affirm that I have a' certificate of consent to self, `I I insure,or a certificate of Workers'Compensation Insurance,or; HEATING-VENTILATING-AIR CONDITIONING U a certified copy thereof(Sec.3800,Lab..C.) I Policy Compan Certified copy is hereby furnished.y COUNTY OF LOS ANGELES BUILDING AND SAFETY ` ❑ Certified copy is filed with the county building inspection FOR APPLICANT'TO FILL IN BUILDING . /s? department. ADDRESS Date Applicant 1 (PRINT OR TYPE ONLY) LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' I NO. TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE • i NEAREST } (This section need not be completed if the work involved ABSORPTION UNIT,BTU CROSS ST. CL by the permit is for one hundred dollars ($100)•or less.) DISTRICT NO. PROCESSED 9Y — U I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM ��QO�/ cc permit is issued, I shall not employ any person in any manner O I-Was to-become subject to the Wo ers'Co ion Laws. BOILER,BTU' ooAPPROVALS - DATE INSPECTOR'S SIGNATURE W Date/!*, )"Applicant COMPRESSOR,BTU QQ�after ROUGH r CO) �7 '�" NOTICE TO APPLICANT: If, aer maki th Certificate of VENTILATION SYSTEM FINAL G� 8( ` Q"�t Z Exemption, you should become subject to the Workers' I Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU041 GRAVITY , LICENSED CONTRACTORS DECLARATION FLOOR: BTU Q ' I.hereby affirm that I am licensed under provisions of Chapter's HEATER: SUSPENDED. UNIT 9 ('commencing with Section 7000)of Division 3 of the Busi- WALL ngss and Professions Code, and my license.is in full force and elect. 36�'''���� License Numbers Lic.Class r d Contractor to I lam axe t from the I -ensing requirements as I am a licensed architect or a registered professional engineer- Plan check fee 25%of above. acting in my professional capacity (Section 7051, Bus- iness and Professions Code). Lic.or Reg.No. Date TOTAL FEE HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from- the Contractor's NAME License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): ADDRESS 1, as owner of the property, will do the work and the TEL.NO. structure is not intended or offered for sale (Section CITY 7044,Business and Professions Code). ❑ OWNER • I 7_3 0 7.2 A I, as owner of the property, am exclusively contracting 00/ id with licensed contractors to construct the , project MAIL # 0 0 0 0 4 1 (Section 7044,Business and.Professions Code). l ADDRESS CONSTRUCTION LENDING AGENCY t' CITY TE.L.NO. ,2o o87.00 I hereby affirm that there is a construction lending agency ` (. for the performance of the work for which this permit is CONTR , a�ACTOR i�Y C f/V o a 0 87005 issued(Sec.3097,Civ.C.). Lender.s Name ADDRESS $ i 1. 14-80 Lender's Address CITY TEL.NO. I certify that I•have read this application.and state that theSTATE r LIC. above information is correct.I agree to comply with all County +. LICENSECLASS ' ordinances and State laws regulating Heating,Ventilating and Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE County to ante up e'above-mentioned property for i1 a 'on purp es. . f `�� Signature of Per t Date