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HomeMy Public PortalAbout6131 TEMPLE CITY BLVD_Mechanical__ WORKERS'COMPENSATION DECLARATION CE813(2-BO) LLe 0��� ®1 ®� i� O� I hereby affirm that 1 have w certificate of consent to suit insure,or a certificate of Workers'Compensation Insurance,or , HEATING-VENT I'I�ATIRts-AIS c®i�DITI®No�lc a c• M led copy thereof(Sec.3800,La .C.) ^^ Po�. Compan Certified copy is hereby 461ed. COUNTY OF LOS ANGELES / BUDDING ARID SAFETY Certified cop) is filed with h building inspection BUILDING department. FOR APPLICANT TO FILL IN `� Date Applicant (PRINT OR TYPE ONLY) ADDRESS-- f LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE NEAREST J a (This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. err/ 0 by the permit is for one hundred dollars (5100) or less.) — Di,TRICT NO PROCESSED Y V 1 certify th.it in the performance of the work for which this AIR HANDLING UNIT,CFM <v f� cc O permit is issued, I shall not employ any person in any manner d so as to become subject to the Workers' Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE 0U Date Applicant COMPRESSOR,BTU / �y ' 390v ROUGH fit'.J '..: C ! r . y NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEMFINAL —�� �' " �1-;-�-- Z 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 he _ deemed revoked. FURNACE: FAU G AVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU oi) b1 lGe 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. 7� License Numb 415—r Lic.Classy//��, Al nr�act'_ Date 1xe t 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 $ ISM Lic.or Rep,.No. Date TOTAL FEE IWO- HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I um exempt from the Contractor's NAME / License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): ADDRESS I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section CITY TEL.NO. 7044, Business and Professions Code). 1, as owner of the property, am exclusively contracting OWNER 4i5 _.7 53 G 1'. with licenced contractors to construct the project MAIL (Section 7044,Business and Professions Code). ADDRESS_ y a 0 0 0 0 CONSTRUCTION LENDING AGENCY CIT _ TEL.N 0 - 3850 I hereby affirm that there is a construction lending agenr) for the performance of the work for which this permit is CONTRACT issued (Sec.3097.Civ.C.). .. . Lender's Name ADDRESS _�_ysr� (1 1,(}5—8 L Lender's Address CITY TEL.NO F certify that I have read this application and state that lite STATE { LIC above information is correct.I agree to comply with all County 11 LICENSE NO. t/ CLASS -e- ordinances and State laws regulating Heating, Ventilating and Air Conditioning,and hereby authorize representatives of this SEE REVERSE.FOR EXPLANATORY LANGI-AGI' C01194y t enter upon the above-mentione pro rty or i� urposes. � / i nature of Permittee Datgf