HomeMy Public PortalAbout6209 TEMPLE CITY BLVD_Mechanical__ WORKER'S L COMPENSATION
ate of consent to 64DPW 9,a9 APPLICATION .FOR PERMIT LUU GREEN
I hereby affir�that L have a certificate of consent to self Insure,
or a certfficate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
UILDING
department. (PRINT OR TYPE ONLY)
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS OR
ABSORPTION UNIT,BTU ASSESSOR
S.
(This section need not be completed if the work Involved by the ° MAP BOOK PAGE 99// PARCEL.
permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO.,, :PaBy
I certify that in the performance of the work for which this permitis isall not employ any person In any manner so s to BOILER,BTUbecome sub ct t he Workers'Compensa' n.Laws. '�
COMPRESSOR,BTU
APPROVALS DATE INSP R'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTIC ROUGH
GTO.APPLICANT: If, after making this ertifi of ../
olfiq
Exem ion,yoli should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU G IZy _ / D VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU rJv�/ (�
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and m license is in full force and effect. '
License Number, Lic.Class ✓ - :I
Contractor j ate / 0 , C
' I am a empf under Sec. Plih Check fee �, C
B.&P.C.for this reason PERMIT ISSUING FEE$ I=
I
Date: TOTAL'FEE O
Signature PLAN CHECK APPLICANT fI
OWNER-BUILDER DECLARATION . 2
I hereby affirm that I am exempt from the Contractor's License Law NAME
for'the'following reason(Section 7031.5, Business and Professions , ACCT
°4
Code): ADDRESS 3303 114.19
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO. IT
.structure is not intended or offered for sale (Section 7044, T04JL '9-m _C1
Business and Professions Code). ` OWNER
❑ I, as owner of the property, am exclusively contracting MAIL ,��„, �V CHECK, 114.10
with licensed contractors to construct the project (Sec- ADDRESS !6°'�// CHANGE
tion 7044,CONSTRUCTION LENDING AGENCY CITY _ TEL. CHANGE °OO
I hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work. for which this permit Is Issued ny(yy i
(Sec.3097,Civ.C.). yQ QO�]11 1
ADDRESS "
Lender's Name I
MP
CITY PTEL.N I
Lender's Address STATE, LIC.
I certify that I have read this application and state that the above LICENSE NO. ( CLASS �
information is correct. I agree to comply with all County ordinances
and State laws relating to buil 'ng construction,and hereby authorize
represent tives of this Cou to enter upon theUE
ntioned
prope for inspection p poses, SEE REVERSE FOR EXPLANATORY LANGUAGE
IGNATURE OF APPLICA R AGEN '