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HomeMy Public PortalAbout5843 TEMPLE CITY BLVD_Mechanical__ WORKERS'COMPENSATION DECLARATION CSA g 8(2=80) �� ®1�I FOR I hereby affirm that I have a' certificate of consent to self f insure, or a certificate of Workers'Compensation Insurance,or FIE:ATING-VENT ILATING-AI IR CONDITIONING a certified copy thereof(Sec.3800,Lab.C.) Policy No. Company I COUNTY OF LOS ANGELES Te BUILDING ARID SAFETY 0 Certified copy Is hereby furnished. Certified copy is filed with the county building inspection BUILDING p department. FOR APPLICANT TO FILL IRI Date Applicant (PRINT OR TYPE ONLY) ADDRESS LOCALITY ? � CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE —NEAREST COMPENSATION INSURANCE I CROSS ST. a :(This section need not be completed if the work involved ABSORPTION UNIT,BTU.by the permit is for one hundred dollars ($100) Or less.) 1' ISTR.ICT NO. PROCESSE Y V 1 certify that in the performance of the work for which this I AIR HANDLING UNIT,CFM ;permit is issued, I shall not employ any person in any manner O 'so as to become subject to Ike Workers'Com ens tin Laws. I BOILER,BTU I" � � � ]Date�.� 9I Applicant u8A COMPRESSOR,BTU d o oROUGH a N EOTICE.TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL �7 - •"° �- 2 xemption, you should become subject to the. Workers' �r (Compensation provisions of the Labor Code; you must forth- ' with comply with such provisions or this permit shall be EVAPORATIVE COOLER �{ VALIDATION deemed revoked. I � FLOOR CE: FAUBTU GRAVITY LICENSED CONTRACTORS DECLARATION 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. pcense Number.'© Lic.Class•'1 SS G C 0 0 ^ i fJ 1 Contractor Date—7 'a — © I I am exempt from the licensing requirements as I am a , I licensed architect or a registered professional engineer I• Plan chec 'fee 25% f above. acting in my professional. capacity (Section 7051, Bus- ! iness and Professions Code). / ! PERMIT ISSUING FEE Lic.or Reg.No.aSlwl S-0 Date � / TOTAL FEE 7 HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 1 hereby affirm that I am exempt from-the Contractor's NAME � License Law for the following reason (Section 7031.5, Busi- ,iess and Professions Code): ADDRESS D I, as owner of the property, will do the work and the CITY TELNO. structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER f I, as owner of.the property, am exclusively contracting with licensed contractors to construct the project I MAIL 71 (Section 7044,Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY CITY TEL.NO. Ihereby affirm that there is a construction lending agency Tov-1L )r the performance of the work for which this permit is CONTRACTOR WedSnde(s Name ADDRESS Civ.C.). ADDRESS !1 9L)q ® 7-G-6?/ :nder's Address CITY(JjAJ a TEL.NO. / Y certify that I have read this application 'and state that the STATE Y1/ � 1 LIC. iove information is correct.i agree to comply with all County LICENSE NO. �5 `�V CLASS `. J -dinances and State laws regulating Heating, Ventilating and 1 Ir Conditioning,and hereby authorire representatives of this SEE REVERSE I.OR EXPLANATORY LANGUA(A ;)u91k to enter up n thabo e-mentioned property for ape t� n p poses. �+' � 5nature of Permittee Dote i