HomeMy Public PortalAbout5780 TEMPLE CITY BLVD_Mechanical__ WORKER'S COMPENSATION DECLARATION zD-D046DPW 9189 APPLICATION FOR PERMIT �
chi`rli �SA364C FEN
I he��d6ffirrl`f tha3 1 have a ceftificate of conserit to self insure,
or 9 certificate of WorRer's Compensation Insurance,or a certified 4' HEATING-VENTILATING-AIR CONDITIONING Cl
copy thereof(Sec.3800 Lab.C.)
ey No. • ompany 5,11AS COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING ss
department. (PRINT OR TYPE ONLY)
Date -�'� ` Applicant j� LOCALITY r&4 N�'r b
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CERTIFICATE OF EXEMPTION FROM WORK S' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work Involved•by the ASSESSOR
MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) IT
I certify that in the performance of the work for which this permit DISTRICT NO. PROCESSED BY •
Is issued, I shall not employ any person in any manner so as to BOILER,BTU '0 p
become subject to the Workers'Compensation Laws. C Q
COMPRESSOR,BTU • L N'
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APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of:the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU (O �� VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT Q
,(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL DM`i"!�
'Professions Code,and my license is in full force and effect. Tiff _I
Le
License Number G2'`nLV Lic.Class �
Contractor ate U ACCT.s C
❑ I am exempt under Sec. Plan check fee �6" ' D
330,E 131.70 C
B.&P.C.for this reason PERMIT ISSUING FEE$ TTS $
Date: TOTAL FEE `I.d u
jOTFiL 131.70 f7
Signature
PLAN CHECK APPLICANT131.70
OWNER-BUI ER DECLARATION •� ' CHECK'
I hereby affirm that I am exe t from the Contractor's License Law NAME 1�, �O + I, CHANGE 000
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS
❑. I, as owner of the property, or my employees with wagesczg
�� _���1 5/25/95as their sole compensation, will do the work and the CITY �`5 TEL.NO. -\
structure is not Intended or offered for sale(Section 7044,
Business and Professions Code). OWNER ri/I I.IA � 1 AAAI-00
❑ I, as owner of the property, am exclusively contracting cs.�WU
with licensed contractors to construct the project (Sec- ADDRESSMAIL A6 r�W�6 n L ,
tion 7044,Business-and Professions Code). p, h
CONSTRUCTION LENDING AGENCY CITY NlllS "I� V TEL.NO.
I hereby affirm that there is a construction lending agency for
the performance of the work CONTRACTOR
for which this permit s issued
(Sec.3097,Civ.C.).
ADDRESS fte33 61 f
Lender's Name CITY "NAigh 11 �, TEL.N
Lender's Address f
I certify that I have read this application and state that the above LICENSE NO. 1 CLCASS
information is correct. I agree to comply with all County ordinances 1
and State laws relating to building construction,and hereby authorise
representatives of this County to enter upon the above-mentioned
property for,ins ect'on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATORE OF APPLI ir
OR AGENT DATE