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Home My Public Portal About6029-6031 TEMPLE CITY BLVD_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C _ I. fiereby affirm that I have a' certificate. of consent;to self. I CE'-818(2-80). A P P L:IC AT I O f FOR: .PERMIT insure,or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIQN.ING a certified copy thereof(Sec.3800.,Lab.C.) G�I" Policy Nd15Lbmpany COUNTY OF LOS ANGELES BUI'LDIN'G AND SAF Y Certified copy is hereby furnished. 3 Certified copy-is ffledWith the county b ilding inspection BUILDING FOR APPLICANT TO FILL IN -•� • de artment ' ,' Dat — Applicant • �` ' (PRINT OR TYPE ONLY) ADDRESS pG P/77 dem t LOCALIT�.•� CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE J � COMPENSATION INSURANCE NEAREST II CROSS ST..' •, d (This section need. not'be completed if the work•involved r ' ABSORPTION UNIT,.BTU p • by, the .perinit is for-.one hundred dollars ($100) or less.) DISTRICT N0. PROCES v V I certify that in the performance of the work for which this I AIR HANDLING UNIT,GFM - permit is issued,I shall not,employ any person in any manner I 1' s l O so as to become subject to the Workers'Compensation Laws. • BOILER,BTU APPRO4A - Date ATE - INSPE.TOR'S SIGNATURE tU ApplicantCOMPRESSOR',.BTU ` RO.UGH � Z —� O. N NOTICE TO APPLICANT: If, after making this Certificate of Z Exemption, you, should' become subject to t;tie Workers' ++ VENTILATION SYSTEM FINAL — Compensation provisions of.the Labor Code, you must forth- Y EVAPORATIVE COOLER VALIDATION + With comply with such. provisions or this permit shall be deemed revoked. FURNACE: FAU VITY LICENSED CONTRACTORS'DECLARATION FLOOR: BTU 20 . I hereby affirm that I am licensed under provisions of Chapter I HEATER: SUSPENDED UNIT 9 (commencing with Section 7000)of Division 3 of the Busi- I' WALL ness and Professions Code, and my license is in full force and effect. License Number a�jpry,l ` a ,Lie.Class Contractor O ' Date - ' Iam exe'inpt,•from the•licensing requirements as I am a j .licensed architect ori a registered profess(onal engineer Plan,check fee 25%of above. acting in,my professional capacity (Section 7051,•Bus-' iness and Professions Code). PERMIT ISSUING FEE$ MID Lie.or'Reg.Np. Date TOTAL FEE HOMEOWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm. that I' am exempt. from- the Contra'ctor's NA lm G -License Law for the following reason (Section 7031.5, Busi- •4 1 4.6 7A ness and Professions Code): ADDRESSJ 7 -AJr •# 0 0 0 0 0 8 I„as owner of the property, will do the work and the f structure Is' not intended or offered for sale (Section CITY TEL.NOS. Z b 7044,Business and Professions Code). OWNER 2r°;° 5 Q 6:Q. ElI, as owner of"the•,property, am exclusively contracting C ° ° ° .5 0,5 0 with licensed contractors to construct the project MAIL (Section 7044,Business and Professions Code). ADDRESS 11 5 2 4— G CONSTRUCTION LENDING AGENCY CITY TEL.NO. I hereby affirm that there is a construction lending agency CONTRACTOR / for the performance of the work for which this permit is Edi B '00" issued Ts N 3097,Civ:C.). r O LenderTs Kerrie ADDRESS -. 'Lend er's.Address CITY_7E_p,_ TEL NOyW4,—P9-1 P 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 Keating,Ventilating and 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 or Permittee Date WORKERS'COMPENSATION DECLARATION F CE-8 4C pp ®e O p PERMIT E®M IT I hereby affirm that I have a' certificate of consent to self CE-818 (2-80) 6'� f"`IC A�' 1� IZ 1 insure,or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITION:IIVC: a certified copy thereof(Sec.3800,L b.C.) Policy IVo'r Company �--" �' Ir •• t .Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDIN AND SAFETY. � � Certified copy is.filed with thecounty building'inspection. FOR APPLICANT TO FILL IN BUILDING d artment. (� Datet pplicant a, „ ` �`- (PRINT OR TYPE ONLY) ADDRESS ate✓ �" CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE'OF APPLIANCE OR EQUIPMENT FEE LOCALITY, .,COMPENSATION INSURANCE NEAREST .(This section need not be completed if the.work involved. ABSORPTION UNIT,BTU CROSS ST. a by the permit is for .one hundred dollars ($100) or less.) DISTRICT NO. PROCESSED BY V I. certify that in the performance"of the work for which this AIR HANDLING UNIT,CFM 'permit is issued, I shall not employ any person in any`manner so as to become subject to the Workers'Compensation Laws. BOILER,BTU APPROVALS DATE INSPECTOR'S SIGNATURE .0 Date ApplicantCOMPRESSOR,BTU- ROUGH �� d ' N.OTWE-TO APPLICANT: If, after making this Certificate of to Exemption, you should become subject to the Workers' VENTILATION SYSTEM FINAL —g Z Compensation provisions of the Labor Code, you must forth- with comply with such provisions,or this permit shall be' EVAPORATIVE COOLER VALIDATION deemed.revoked. 3 LICENSED CONTRACTORS'DECLARATION FURNACE: FAU GRAVITY FLOOR: BTU I hereby affirm that I arri licensed under provisions of Chapter. HEATER: SUSPENDED UNIT •9^(commencing with Section 7000)of Division 3 of the Busi- I WALL ness and Professions Code,,and my license is in.full.force and effect. ' • License Number 7# yeFro Lic.Class Contractor• 11�U /TLSO Date F1 I am exempt from the licensing requirements as I'am it licensed architect. or a registered professional engineer Plan check fee.25%ot abbv,e. acting in'my professional capacity (Section 7051•, Bus- " iness and Professions Code). ' ' PERMIT ISSUING FEE$ d7 Lic.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 /'1t G d License Law for the following reason (Section 701.5;Busi- vAl,ess and Professions Code): ADDRESS � y 7 14,66 A . I, as owner of the property,,will do the work-and the �� I structure i$ not intended or offered for sale (Section Cl �yn E TEL.NO- ' # o'o-0 0 o $ 7044,Business and Professions Code). TrM O W N E R t.J'1-I.�.�. R 2 o 5 0.6 0 .I,as pwner Q£the property,•am exclusively contracting with licensed""•contractors to construct the project MAIL o 6'0 5 Q 5(7� (Section 7044;Business and,Professions Code). ADDRESS i CONSTRUCTION LENDING AGENCY CITY TEL.NO. Q a,2'4'—8 4 I. hereby affirm that there is a construction lending agency r for the performance of'the work for which this permit is CONTRACTOR issued Tec.3097,Civ.C:). Lender s Name ADDRESS F0 ,Gd Lender's AddressCI•T TEL.NO. I certify that 1 have read this application and state that the STATELIC. above information is correct.I agree to comply with all County LICENSE NO. CLASS ordinances and State laws regulating Heating,Ventilating and Air Conditioriing, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE County .to enter upon the above-mentioned property for ins pe 'on purposes Signal re of Permittee Date - _ -