HomeMy Public PortalAbout6022-6024 TEMPLE CITY BLVD_Mechanical__ 1 V.,.,WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
:,I h'erebrj affirm that I'have a certificate of consent to self
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CE-818(REV. 10/81)
Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy'is hereby furnished.
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS Q - �,P /rP !/
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY
I NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST —
COMPENSATION INSURANCE CROSS ST.00,y,7,6 rO'/�
ABSORPTION UNIT,BTU DISTRICT NO. PROCESSED BY
(This section need not be completed if the work involved by
the permit is for one hundred dollars(E100)or less.) AIR HANDLING UNIT,CFMt o�
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 t9 become subject to the Workers'Compensation Laws. APPROVALS DATE INSP T RS SIGNATUR
COMPRESSOR, BTU ROUGH ,
Date � is pPlicant� '�
NOTIC TO PPLICANT: If, after m ng this Certificate of VENTILATION SYSTEM FINAL3 Mao,
Exemption, you should become subject to the Workers' ✓
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDAT
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. // �
0
License Number Lic. Class , %P
Contractor Date
❑ I am exempt under See. V
W
Plan check fee
B.BP.C. for this reason' Z
Date: PERMIT ISSUING FEE$ U
Signature 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 t
Professions Code):
El I,,as owner of the property,'or my employees with ADDRESS 5 O 6 A
wages as their sole compensation,will do the work,andCITY TEL. NO. # o 0 0 0 0 8
the structure is not intended or offered for sale(Section
7044, Business and Professions Code).
OWNER / ( ° ° 2 a O
❑ I,as owner of the property,am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL ADDRESS 0 ° ° 2 Q 5 O 5
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING.AGENCY CITYTEL. NO. ,6 S� 0 7 1 5-8 b
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACT R
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
CITY TEL. NO.
Lender's Address
STATE LIC. •
I certify that I have read this application and state that the I 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
mon!be abo e-mentio ed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
r 7 5"
Signature !pplicani' gent aDat f
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