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Home My Public Portal About5910 TEMPLE CITY BLVD_Mechanical__ WORKERS'COMPENSATION DECLARATION CE 818 c2_g0) APPLICATION FOR PERMIT I hereby affirm that I have a' certificate of consent to self I insure,or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING ,.,,acertif��jjed copy ther�rof(9Sec.3800,Lab.C.) I I PolicyP ~7/—,��•�C"ompany�if/d. o lrt��'r y a?a'7- 975 Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county building inspection i BUILDING ✓fes de�,aart/me,,nty� �.�� FOR APPLICANT TO FILL IN A0DRESS,.'f Date J��f�-- ^pplicant�c'. I (PRINT OR TYPE ONLY) LOCALITY CERTIFICATE OF EXP PTI ORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE >� a COMPENSATION INSURANCE NEAREST CROSS ST. (This section need not be completed if the work involved I ABSORPTION UNIT, BTU a by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PRO s BY 01 U I certify that in the performance of the work for which this l AIR HANDLING UNIT,CFM � �- F3: permit is issued, 1 shall not employ any person in any manner I so as to become subject to the Workers'Compensation Laws. + BOILER,BTU APPROVALS DATE INSPECTOR'S SIGNATURE W Date Applicant COMPRESSOR,BTU Q 0 Sd6 ROUGH fc:c�,••�� O. �. N NOTICE TO APPLICANT: If, after making this Certificate of i VENTILATION SYSTEMFINAL ")d � R� Z Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deemed revoked. a FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR: BTU I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT e,"9 (commencing with Section 7000)of Division 3 of the Busi- WALL ness and Professions Code, and my license is in full force and effect. a i/j License Numbe O — Lic.Class Contract o N�.lt- ate• A—/Io '•�,./ \ exem fAi� icensing requirements as I am a licensed architect or a registered professional engineer I Plan check fee 25%of above. acting in my professional capacity (Section 7051, Bus- iness and Professions Code). l PERMIT ISSUING FEE$ eF Lic.or Reg.No. Datei TOTAL FEES Sa I i HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from- the Contractor's NAME r'3 1 1.2 A License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): ADDRESS o o 0 o o 8 I, as owner of the property, will do the work and the I CITY TEL.NO. 2 0 0 2 a50 structure is not intended or offered for sale (Section I i'.' 7044,Business and Professions Code). OWNERc , / n o 0 2 3.S 0 5 ❑ �J, I, as owner of the property, am exclusively contracting rte/,, with licensed contractors to construct the project MAIL �` �! ( i �/ 0301 ,-82 (Section 7044,Business and Professions Code). ADDRESS •�7/ �•�g T /-V4 • CONSTRUCTION LENDING AGENCY CITY Lf TEL.NO. I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is CONTRACTOR issued Dec.3097,Civ.C.). Lender s Name ADDRESS Lender's Address CITY TEL.NO. �_A111-10� e � I certify that I have read this application and state that the STATELIC. _Ar above information is correct.I agree to comply with all County LICENSE NO. CLASS ordinances and State laws regulating Heating, Ventilating and Air Conditioning,and hereby authorize representatives of this I SEE REVERSE FOR EXPLANATORY LANGUAGE Count to enter upon the above-mentioned property for ( i on purposes. ignature of Permittee Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a.;,'_rtifled copy thereof(Sec. 3800, Lab. C.) 76A364C CE-818(REV. 10/81) Policy No. Company Certified copy is,hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion department. (PRINT OR TYPE ONLY) ADDRESS / /V Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT• FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. tff�2 BTU DISTRICT NO. PRO ED Y (This section need not be completed if the work involved by ABSORPTION UNIT,the permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM t I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner BOILER,BTU so as to become subject to the Workers'Compensation Laws. APPROVALS DATE ISP DR'S STONATtpli l. . 1 Date ° � Applicant I COMPRESSOR,BTU ROUGH 4 fd NOTICE TOAPPLICANT: 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 VALIDATIO with comply with such provisions or this permit shall be :0 5 8 9 6 A deemed revoked. IFURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU # 0 0 0 0 2 2 1 hereby affirm that I am licensed under provisions of Chapter 9 HEATER: WALL NDED UNIT I o o 11 250 '(commencing with Section 7000)of Division 3 of the Business =, and Professions Code,and my license is in full force and effect. 0 0 0 12 5 0:05 IP_ cc License Number Lic. Classto 1,0'�—8 6 to � O Contractor ❑ I am exe t under Sec. 916� Plan check feebcCU ft IF,', Y,p o B.BP.C. for this reason' PERMIT ISSUING FEE Date: Signature TOTAL FEE OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT AP6 0 5 8 A I hereby affirm that I am exempt from the Contractor's License Poo for the following reason (Section 7031.5, Business and � � &C;A1s' 1p we # o a o o 2 Professions Code): A' ( 0 0 0 [(,0 0 El1, as owner of the property, or my employees with ADDRESS >V& o l� w 10o a o o p,0 0 05 wages as their sole compensation,will do the work and CITY A , .p TEL. NO. .1s the structure is not intended or offered for sale Section ( 2 0 4 -$6 Ol I 7044, Business and Professions Code). OWNER ;26059A • ❑ I, as owner of the property, am exclusively contracting # 0 0 33.50 with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS # o 0 0 0 0 8 CITY TEL. NO CONSTRUCTION LENDING AGENCY . I hereby affirm that there is a construction lending agency for 1 o o 33.50 the performance of the work for which this permit is issued R � � Gam' ,n 8 6 csi (Sec. 3097, Civ. C.). Vr.��Y II` f� ADDRESS /0 Af &4 gtjp �a—y Lender's Name. 50 • CITY�` . NO. Lender's Address. STATEJ LIC. I certify that I have read this application and state that the LICENSE NO.� CLASS above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter up o -t above-f nt� ed property for inspection p p ses. SEE REVERSE FOR EXPLANATORY LANGUAGE ao Signature of Applicant or Agent Date f