HomeMy Public PortalAbout6204 TEMPLE CITY BLVD_Mechanical__ WORKER'S COMPENSATION DECLARATION 120-0048 DPW 9/89 L� E GREEN
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i7BA364C r APPLICATION EF®I!�'PERMIT
I here by;atrlfrl�that I have a certi}icate of consent to self insure,
or aJcertifloats of Worker's Compensation Insurance, or a certified - HEATING-VENTILATING-AIR CONDITIONING
copy thereof JSec.38800�Lab.C.)
`�lNd 7% / Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
Certified copy is filed with the cc building inspection FOR APPLICANT TO FILL IN BUILDING ' r z�
/department. (PRINT OR TYPE ONLY) ADDRESS Co [rL
Date / `_9 Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST /Qn J
COMPENSATION INSURANCE CROSS ST. L— (�
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed If the work Involved by the MAP BOOK PAGE PARCEL
permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
' DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. ,
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
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provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION I FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT /�
(commencing with Section 7000)of Division 3 of the Business and I l HEATER: WALL d 3
Professions Code,and my license is in full force and effect.
License Number 6% ?iyj� LI..Class 620
_ I ® Q
Contracto e Date !o O _5 Z-
3 I Plan check fee L
❑ I am exempt under Sec. I D
BAP.C.for this reason PERMIT ISSUING FEE$ F
Date: I TOTAL FEEd V
9 I 1D
Signature PLAN CHECK APPLICANT U
OWNER-BUILDER DECLARATION I s
1 hereby affirm that I am exempt from the Contractor's License Law NAME C
for the following reason(Section 7031.5, Business and Professions I
Code): I
❑ ADDRESS
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). OWNER 't
Phi
❑ 1, as owner of the property, am exclusively contracting Ili- 4:8 o 173 Of
MAIL
with licensed contractors to construct the project (Sec- ADDRESS I "r! +' -
tion 7044,Business and Professions Code). !"v,
CITY TEL.NO.
CONSTRUCTION LENDING AGENCY �7Z4 CIANGEE °'_::
I hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit Is issued
(Sec.3097,Civ.C.). 40
ADDRESS r r�_ I I./i .f_li;f 92
Lender's Name VVO�O ;,,., ,° -
CITY NO. t 1 A i l g a t
Lender's Address STATE LIC.
I certify that I have read this application and state that the above I LICENSE NO. c5 6 CLASS C Z (�
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
or inspects pur oses. I SEE REVERSE FOR EXPLANATORY LANGUAGE
SIR&WRE OF APPLICANT CIA AGENT DATE