HomeMy Public PortalAbout6213 TEMPLE CITY BLVD_Mechanical__ WORKER'S COMPENSATION DECLARATION �BA3840 PW 9/89 APPLICATION FOR PERMIT
I hereby affirin•that I have a certificate of consent to self insure,
or a cerifficate•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 co is filed with the count buildingInspection FOR APPLICANT TO FILL IN BUILDING
copy y PRINT OR TYPE ONLY) ADDRESS
department. ( YI
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS
COMPENSATION INSURANCE
ABSORPTION UNIT,BTU ASSESSOR
�s`
(This section need not be completed if the work Involved by the MAP BOOK 62'd cJ PAGE Q// PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO PR
Mie
I certify that in the performance of the work for which this permit
is issued, I shall not mploy any person in any manner so as to BOILER,BTU ����
become subjec o th Workers'Compensation s. , 0
�-
COMPRESSOR,BTU
•� APPROVALS DATE INSP 'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE O A PL CANT: If, after making this Certificate of ROUGH
Exempt' n,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU 7V I
LICENSED CONTRACTORS DECLARATION FLOOR BT VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license in fu rce and effect. D
License Number a Lic.
f t ► a
Contractor Date C,
❑ is a empt under Sec. Plan Check fee
d
B. C.for this reason PERMIT ISSUING FEE$ F
f
Date: TOTAL FEE 0 U
u
Signature
PLAN CHECK APPLICANT C
OWNER-BUILDER DECLARATION n� n
I hereby affirm that I em exempt from the Contractor's License Law NAME ® 3303 114.10
for the following reason (Section 7031.5, Business and Professions 1 ITEMS
Code): ADDRESS r� -n
❑ I, as owner of the property, or my employees with wages TOTAL -It �-' 'a
as their sole compensation, will do the work and the CITY TEL.NO. 4ftE4� 114.10
structure is not intended or offered for sale(Section 7044, CH
Business and Professions Code). OWNER / ��+ CHANGE ,0
❑ 1, as owner of the property, am exclusively contracting MAIL �!
with licensed contractors to construct the project (Sec- ADDRESS J �� J
tion 7044,Business and Professions Code). CIT ' L.N � UtlL1tJ 1/95
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lending agencyCONT
for Ry� ® 1630 1 AM 9"11
the performance of the work for which this permit is issued ACTORl"
(Sec.3097,Civ.C.).
ADDRESqNO_ CLASS Lender's Name
CI TEL.N
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENS
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
represented as of this Count ta enter upon the a ve- entioned
property r in ction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Gi TURE OF APPLICANT OR AGENT DATE