HomeMy Public PortalAbout5753 TEMPLE CITY BLVD_Mechanical__ 7,6A364C
WORKERS'COMPENSATION DECLARATION .� „ v PE-36 8(2-80) A P P UC A u �®i�I FOR P E R U�711 T
I hereby affirm that I have a• certificate of conseriV to self,
insure,or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR NTIL.ATING-Alla CONDITIOI ONG
a certified copy thereof(Sec.3800,Lab.C.) "fl
Policy No. Company.
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES � BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspection FBILDING ` 5'3>
+
department. FOR APPLICANT TO FILL IN DRESS 4S 7 J � N • t ���� �T
Date Applicant (PRINT OR TYPE ONLY)
CERTIFICATE OF EXEMPTION FROM WORKERS'
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CALITY C r
COMPENSATION INSURANCE NEAREST }
(This section need riot be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. �(% I�Y.�✓fi�� 0
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. O Es v V
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM Ocp,., ¢
permit is issued, I shall not employ any person in any manner LI-0
so as.to become subject to the Workers.'Compensation Laws. BOILER,BTU
APPROVALS DATE CTOR'S S ATURE• W
.Date Applicant COMPRESSOR,BTU: O O� ROUGH -� N
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL - Z
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. EJJDV O : FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU a
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with.Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and
effect.
License Number Lic.Class
Contractor Date i
❑ I am exempt from the licensing requirements as I am'a \
licensed architect or a registered professional engineer Plan check'fee 25%of above.
acting in my professions;capacity (Section 7051, Bus- PERMIT ISSUING FEE$
iness and Professions Code).
Lic.or Reg.No. Date I 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 2 0 1 0 6 A
25 I, as owner of the property,will do the work and the PITY TEL.NO.
structure is not intended or offered for sale (Section
k o 0 0 0 [I 1
7044,Business and Professions Code).: 2�
El 1,
y/C M ✓ L 0 027.00
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project 1 AIL r
(Section 7044,Business and Professions Code). DDRESS . 7 1-7-4 C t o 0 o i 7,0�
CONSTRUCTION LENDING AGENCY PONTRACT;OR
TEL.NO. 0609-81
I hereby affirm that there is a construction lending agency
for the performance of. the work for which this permit is issued Sec.3097,Civ.C.).
Lender s Name Lender's Address L•
I certify that I have read this application and state that the TATE LI
above information is correct.1 agree to comply with all County (CENSE NO. CLASS
ordinances and State laws regulating Heating,Ventilating and
Air Conditioning,and hereby authorize representatives of this SEE.REVERSE FOR EXPLANATORY LANGUAGE
tign
tyto enterution purposature of Permittee Date