HomeMy Public PortalAbout6211 TEMPLE CITY BLVD_Mechanical__ WORKER'S6' ' aENSAicate of consent to 2"048 DPW
PW9/89 APPLICATION FOR PERMIT L� EGREEN
I hereby afffrirrthat t have a certificate of consent to self Insure,
or''a certificate 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. / �y
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
ADDRESS
department. (PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST•
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
- ASSESSOR
(This section need not be completed If the work Involved by the MAP BOOK PAGE d// PARCEL,40
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is Issued, I shall not employ any person in any manner so as to BOILER,'BTU y
become ub ct t the VII ers'Compensati n Laws.
COMPRESSOR,BTU
Daie. Applicant ° VENTILATION SYSTEM APPROVALS DATE INSPECTOR'S SIONA7URE
NOTICVE T APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should-liecome subject to the Workers'Compensatidn EVAPORATIVE COOLER
provisions of the Labor Code,you must'forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU G nY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VAL•(DATION
I hereby affirm,that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of DiJision 3 of the Business and I HEATER: WALL
Professions Code,and my license is In full force and effect. 1
License Number LID.Class
I }
Contractor � , C
❑ Plan check fee C
I.am a mpt under Sec. Ix
B.&P.C.for this reason I PERMIT ISSUING FEE$ 60 tC-
Date: LL
TOTAL FEE �/ / S " 11
• Mh
Signature PLAN CHECK APPLICANT ACCT o v V
OWNER-BUILDER DECLARATION �TA4 ii�e�� �_
I hereby affirm that I am exempt from the Contractor's License Law NAM303 E ,
for the following reason(Section 7031.5, Business and Professions 1 ITEMS
❑Code): ' ADDRESS ITOTAL 11.4 m ID
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO.- ({J�/ 11(fa„{A►
structure is not Intended or offered for sale(Section 7044, l4+IM7! U(J
Business and Professions Code). OWNER
❑ I,-as owner of the property, am exclusively contracting MAIL•
With licensed contractors to construct the project (Sec- ADDRES '
tion 7044,Business and Professions Code). 7 COQ—Q001 S/ 1f9'
' CONSTRUCTION LENDING.AGENCY CITY T/.N .
I CONTRACTOR hereby affirm that there Is a construction lending agency for 1629 1 AM ��11
the performance of the work for which this permit Is issued ,
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name CITY TEL. °
Lender's Address STA E V / LIC.
I certify that I have read this appli ation and state that the above LICENSE NO. �j CLASS G�
Information is correct. I agree to ply with all County ordinances
and State laws relating to buildin onstruction,and hereby authorize
repress fives of this Count enter ,pon the ab e- entione
prope for i 'spectio pur as.
SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT O GE DIATE