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Home My Public Portal About5953 TEMPLE CITY BLVD_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby,,affirm that"I have o certificate of consent to self .in§ure, or a certificate of Workers' Compensation lifsurance, HEATING - VENTILATING - AIR CONDITIONING c or a ertified co thereof (Sec. 3800, Lab. C.) 76A364C �d 20-0046 DPW 9/88 olicy No� D Companyvs:� , Certified copy I hereby furnished. , COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING s�y—� ��," �T� >�v Tion department. ADDRESS J B—nn (PRINT OR TYPE ONLY) �! — q licant /,s/� /�//V-S�i��1d�G LOCALITY ZW TC Date PP � NO. TYPE OF APPLIANCE OR EQUIPMENT FEE L CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed If the work Involved by ABSORPTION UNIT, BTU I DISTRict NO. SSED BY the permit is for one hundred dollars(;100)or less.) AIR HANDLING UNIT,CFM �( I certify that in the performance of the work for which this (J G 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 INSPECTOR'S SIGNATURE DateApplicant COMPRESSOR, BTU ROUGH I f NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM / ' D_Q FINAL Exemption, you should become subject to the Workers' n 4��_ . . I/ V111 Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER / a// VALIDATION .with.comply with such provisions or this permit shall be deem- VVV ed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPENDED—UNIT— (commencing with Section 7000)of Division 3 of the Business WALL. and Professions Code,and my license is in full force and effect. 06} License Number Lic. Class ► O �� -�� " Contractor�f 5:912, //Aute � ❑ I am exempt under Sec. V Plan check fee Lu B.&P.C. for this reason / d PERMIT ISSUING FEE $ 6 Z ' D e: • Signature flu I TOTAL FEE OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License , Law for the following reason (Section 7031.5, Business and NAME Professions Code): ❑ 1,-as owner of the property, or my employees with ADDRESS ACCToav wages as their sole compensation,will do the work and CITY TEL. NO. :� the structure is not intended or offered for sale(Section 3 � 3r ,51 7044, Business and Professions Code). OWNER' 1 ITEMS ❑ I,as owner of the property; am exclusively contracting with licensed contractors to construct the project (Sec- MAIL I' i'�� ,� � tion 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY Cin. TEL. NO. CHECK 30.50 1 hereby affirm that there is a construction lending agency for ,�p� the performance of the work for which this permit is issued CONTRACTOR CHANGE ' °0I0 (Sec. 3097, Civ. C.). ADDRESS Lender's Name 0000-0001 11/21/89 CITY TEL. NO. Lender's Addres's 6938 1 AM11=i0 I cern that I have read this application and state that the STATE LIC. certify PP 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 reptatives of this County to enter upon the b ve- ention operty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date co ®; WORKERS' COMPENSATION DECLARATION I herebY Gffirm thdf I have a certificate of ionsent to self. APPLICATION FOR PERMIT ins ire, o�a certificate of Workers' Compensation lhsurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof(Sec. 3800, Lab. C.) 76A364C' —.1 20-0046 DPW 9/88 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 Sr.1..7 LrE G 7Y g LV Date Applicant LOCALITY Tc— � MA NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE i CROSS ST. (This section need not be completed if the work involved by ' ABSORPTION UNIT, BTU DISTRIC�j T N PROC sv the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM I certify that in the performance of the work for which this ✓ f permit is issued, I shall not employ any person in any manner. BOILER, BTU so at to become subject to the Workers'Compensation Laws. APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant COMPRESSOR, BTU ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Ally 0 Z/ Exemption, ;you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- ' EVAPORATIVE COOLER �i+ b VfALID with comp)y with such provisions or this permit shall be deem- L� ed revoked. FURNACE: FAU GRAVITY Vv�f LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am.licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT— ''}3 (commencing with Section 7000)of Division 3 of the Business WALL. '- and Professions Code,and my license is in full force and effect. J AG'(■e } I�IM V191 t - L, JkAAA r�L License Number Lic. Class , �7 ■ '0 Contractor Date I ITEMS m ❑ I am exempt under Sec. TOTAL 12.5d Plan check fee CHECK i�■ B.BP.C. for this reason I q ` PERMIT ISSUING FEE $ O� HA ■ UZ 1 Date: Signature TOTAL FEE OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 9/27/$9 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and NAME 5919 1 AM 9 56 Professions Code): ii El 1, as owner of the property, or .mADDRESS., employees with - wages as their sole compensation,.will do the work and CITY TEL. NO. qbO 0� the structure is not intended or offered for sale(Section 17 l V 7044, Business and Professions Code). OWNER ` ❑ I,as owner of the property, am exclusively contracting - I" with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS, ((Q2 N-t CONSTRUCTION LENDING AGENCY ' CITYI TEL.`NO. ; j I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR ` (Sec. 3097, Civ. C.). ADDRESS -� Lender's Name r� CITY TEL. NO. Lender's Address STATE LIC. - I cer`•tify'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 upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature a�f Applicant or Agent Date WORKERV COMI`&SATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self insunt or a certificalt of Workers'Compensation Insurance, or p ce76A964C HEATING - VENTILATING - AIR CONDITIONING rt4 ied coy thereof(Sec. 3800, Lab. C.) r�' CE-818(REV. 10/81) P❑ollcy No. Company_ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY QCertified copy is filed with t e county building inspec- FOR APPLICANT TO FILL IN BUILDING p '' j ti dfe �axtr-t)rment. 1 (PRINT OR TYPE ONLY) ADDRESS �ef ��t �J�� Date I I v `I, Applican L LOCALITY Pf C,' ` t `` NO. TYPE OF APPLIANCE OR EQUIPMENT FEE tom` CERTIFICATE OF EXEMP OIC(FROM WORKERS' NEAREST COMPENSATIO INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO.AIR HANDLING UNIT,CFM PROCESSED the permit is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this (,J 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 DATEI TOR'S SIGNATIJ Date Applicant COMPRESSOR,BTU " r ' V 0 ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL v Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER If A'In AT' with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT '(commencing with Section 7000) of Division 3 of the Business , WALL and Professions Code,and my license is in full force and effect. p'4- O License Number� Lic. Class `t ContractorVORAL� Date O ❑ I am exempt under Sec. V W Plan check fee a y BAP.C. for this reason' � Date: PERMIT ISSUING FEE $ Signature TOTAL FEE -2 7 7 7.9 A OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License , Law for the following reason (Section 7031.5, Business and NAME # 0 0 0 0 0 (3 Professions Code): ❑ 1, as owner of the property, or my employees with ADDRESS .1 o o 2 a 5 p wages as their sole compensation,will do the work and CITY TEL. NO. ° ° ° 2 Q 5 Q c�i the structure is not intended or offered for sale(Section 7044, Business and Professions Code). OWNER Ai a 2 7 8 7 ❑ I, as owner of the property,am exclusively contracting _ with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITYTEJtJ gfJa'JTEL. NO. I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR VJU—L '�,-" W rel (Sec. 3097, Civ. C.). Lender's Name ADDRESSWI D `��+�•^II f ' CITY ''; TEL. NO.Z1 - O� Lender's Address STATEy LIC. I certify that I have read this application and state that the LICENSE NO.'Jf.7_-) CLASS �n 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 upon a above-mentioned p perty for i spe tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE $ i 21 (Signature of Applicant or Agent i ) Date