HomeMy Public PortalAbout5926 TEMPLE CITY BLVD_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA 818 (2-80) APPLICATION FOR PERMIT
I hereby affirm that I have a' certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec. 3800,Lab. C.)
i
Policy No. Company
❑ Certified copy is hereby furnished.
COUNTY OF LOS ANGELES BUILDING,AND SAFETY
Certified copy is filed with the countybuilding inspection
department. FOR APPLICANT TO FILL IN BUILDING
Date Applicant (PRINT OR TYPE ONLY) ADDRESS _
i; LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE _.
COMPENSATION INSURANCE NEAREST d
(This section need not be completed if tyle work involved ABSORPTION UNIT, BTU CROSS ST. O
'by the permit is for one hundred dollars ($100) or less.) DISTRICT NO PROCESS,o By U
'I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM LU
permit is issued, I shall not employ any person in any manner ' ! `` ° - LL
so as to become subject to the Workers' Compensation Laws. BOILER, BTU
APPROVALS DATE INSPECTOR'S SIGNATURE �..
Date .Applicantcc
COMPRESSOR,BTU
ROUGH Q
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM cc
Exemption, you should become subject to the Workers' FINAL 4
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. UJ
FURNACE: FAU GRAVITY-
LICENSED
RAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU
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 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 professional capacity (Section 7051, Bus
mess and Professions Code). PERMIT ISSUING FEE $
Lic.or Reg.No. Date TOTAL FEE
z 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-
nessand Professions Code): ADDRESS r
r ❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section CITY TEL. NO.
t 7044, Business and Professions Code).
❑ OWNER
f Y I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL + + w
f (Section 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY 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 (Sec. 3097,Civ.C.).
Lender's Name ADDRESS
Lender's Address
CITY TEL. NO.
I certify that I have read this application and state that the STATE LIC.
above information is correct.I agree to comply with all Count, [LICENSE NO. CLASS
ordinances and State laws regulating Heating, Ventilating anc
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above-mentioned property for
inspection purposes.
i
Signature of Permittee Date
APPLICATION FOR PERMIT
wORKERS �pMPI;NSATION DECLARATION 76A364C
I hereby affirm that I have a' certificate of consent to self CE 818 12-80)
insure, or a certificate of Workers'Compensation Insurance,oir HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec. 3800, Lab.C.)
Policy No. Company
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspection BUILDING
department. FOR APPLICANT TO FILL IN ADDRESS
.Date Applicant (PRINT OR TYPE ONLY) ---- }
LOCALITY ty
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE _ —_--_ Q
COMPENSATION INSURANCE NEAREST U
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. J
by the permit is for one hundred dollars (5100) or less.) DISTRICT NO. PROCJefD BY _
J certify that in the AIR HANDLING UNIT,CFM #� V
y performance of the work for which this
'permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws. BOILER, BTU Q
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant COMPRESSOR, BTU 0
ROUGH O
NOTICE TO APPLICANT: If, after making this Certificate ofQ-
Exemption, you should become subject to the Workers' VENTILATION SYSTEM FINAL W
W
Compensation provisions of the Labor Code, you must forth- VALIDATION ~
with comply with such provisions or this permit shall be EVAPORATIVE COOLER
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS bECLARATION FLOOR BTU `
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 Lie.Class_
Contractor Date
❑ 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 professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE $ cr
Lie.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
structure is not intended or offered for sale (Section CITY TEL. NO. r r
7044, Business and Professions Code). {
❑ OWNER a ♦ a `
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL t .
(Section 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY 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(Sec. 3097,Civ.C.).
Lender's Name ADDRESS
Lender's Address CITY TEL. NO.
I certify that I have read this application and state that the STATE LIC.
above information is correct.I agree to comply with all County LICENSE NO. CLASS
ordinances and State laws regulating Heating, Ventilating and Y
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above-mentioned property for
inspection purposes.
Signature of Permittee Date