The URL can be used to link to this page

Home My Public Portal About6042-6044 TEMPLE CITY BLVD_Mechanical__ WORKERS'COMPENSATION DECLARATION ^ ; CEA38 8(2-80) fA lid lid II C ,A Ti �O N FOR R P E lid f�,Cl T I hereby affirm that I have a' certificate of cfJnsent to'self i �1 Ir I! L� 6�l d 1�l If If�C LS If�S II�Yp insure,or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING "fl a certified copy thereof(Sec.3800, a C) Policy No. S�3�mpany-�� COUNTY OF LOS ANGELES BUILDING AND SAFETY F1 Certified copy is hereby furnished. Certified copy is filed with t my bu g' pection I BUILDING �D 7 � /4 par �e FOR APPLICANT TO FILL IN ADDRESS 7 el40 Date Applicant (PRINT OR TYPE ONLY) • CERTIFICATE OF EXEMPTION FR M V ORKERS' I NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY NEAREST COMPENSATION INSURANCE i CROSS ST. d (This section need not be completed if the work involved ABSORPTION UNIT,BTU by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSED V I certify that in the performance of,the work for which this AIR HANDLING UNIT,CFM W permit is issued, I shall not employ any person in any manner S, t7 O' so as to become subject to the Workers'Compensation Laws. I BOILER,BTUr pplo APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant COMPRESSOR,BTU✓O ROUGH � CL NOTICE TO APPLICANT: 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 VALIDATION with comply with such provisions or this permit shall be Q deemed revoked. FURNACE: FAU GRAVITYO LICENSED CONTRACTORS DECLARATION FLOOR! B U 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• i' WALL ness and Professions Code, and my license is in full force and effect. l License Number Lic.Clasys �� C) Contractor r -E ate ■5 nf!+C�� I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer I Plan check fee 25%of above. acting in my profession;capacity (Section 7051, Bus- iness and Professions Code). Lic.or Reg.No. Date I TOTAL FEE &0 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 _0 6 2 3 A I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section CITY TEL.NO. $''0 0 0 o o8 ' 7044,Business and Professions Code). I, as owner of the property, am exclusively contracting OWNERi5el ! ° 1'1'0.'5'0 with licensed contractors to construct the project MAIL (Section 7044,Business and Professions Code). ADDRESS �^ ° 1. 1 0,u Q 5 CONSTRUCTION LENDING AGENCY CITY TEL.NO. _n 3 2 1 —8 3 I hereby affirm that there is a construction lending agency CONTRACTOR ' for the performance of the work for which this permit is e y- Cha ,IV issued fSec.3097,Civ.C.). Lender s Name ADDRESS 7.;?6 Y Lender's Address CITY. L.NO. I certify that I have read this application and state that theSTATE �y�� LIC. 7 above information is correct.I agree to comply with all County LICENSE O. (JUN CLASS ordinances and State laws regulating Heating,Ventilating and Air Conditioning, d reby.author'ize representatives of this SEE REVERSE.FOR EXPLANATORY LANGUAGE County to ent u n above-mentioned properly for in ec ' n purp s. I ignature of Vltt,44 Date WORKERS'COMPENSATION DECLARATd6NCEA g6 8, (2-g0) APP LLQ�C A tl �® (N FOR P E R� T I hereby affirm that I have a' certificate of consent to self insure,or a certificate of Workers'Compensation Insurance,or HEATING-VENT ILATING-Alla CONDITIONING a certifiedp/Sgr3 f(Sec.3800�+�►gb. � , Policy No. 8 �'7Company S-/ ' COUNTY OF LOS ANGELES BUILDING ARID SAFETY Certified copy is hereby furnished. ® Certified copy is filed with the county buil ection FOR APPLICANT TO FILL IN BUILDING ` Dated Partin ` Applicant • (PRINT OR TYPE ONLY) ADDRESS 6O /C 6/• LOCALITY CERTIFICATE.OF EXEMPTION FRO WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE l COMPENSATION INSURANCE NEARESTCROSS ST. `'L/i/ a (This section need not be completed if the work involved ABSORPTION UNIT,BTU p by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSE BY V I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM Cc permit is issued, I shall not employ any person in any manner Seo O so as to become subject to the Workers'Compensation Laws. BOILER,BTU 1— �/� APPROVALS DATE INSPECTOR'S SIdNATURE W Date Applicant COMPRESSOR,BTU sS(� ROUGH �'(WT -15 P ��'�` N NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL o �+-' z Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLE VALIDATION with comply with such provisions or this permit shall be deemed revoked. FURNACE: 'FAUB U GRAVITY— LICENSED RAVITY LICENSED CONTRACTORS DECLARATION 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•Z6sLLL ic.Class ~°2 Contractor -�Date Fi I am exemp 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 - PERMIT ISSUING FEE iness and Professions Code). Lic.or Reg.No. Date TOTAL FEE D 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 -O b 2 2 A ElI, as owner of the property, will do the work and the *TEL.NO. 8 structure is not intended or offered for sale (Section I CITY j: o o e o 0 7044,Business and Professions Code). OWNER Z o Q,S Q I, as owner of the property, am exclusively contracting � O with licensed contractors to construct the project MAIL IO 50 0, 5 0 (Section 7044,Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY CITY TEL.NO. 0321 —83 I hereby affirm that there is a construction lending agency CONTRACTOR for the performance of the work for which this permit is �c, issued Sec.3097,Civ.C.). 01 Lender s Name ADDRESS Al. 'L' p' 6 Lender's Address [STAT:E ITY L.NO.96 ;j7/ I certify that I have read this application and state that the . LIC., above.infor.mation is correct.I agree.to comply With all County ICES NO. 0 3l CLASS ordinances and State laws regulating Heating, Ventilating and Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE County to ent p the above-mentioned property for in a on pur 4 Signature of mi a Date _