HomeMy Public PortalAbout6243 TEMPLE CITY BLVD_Mechanical__ WORKI RS'CODIPI NSA]ION DLCLA RATION 76A364C
I herLb) affirm that I have a Lerldlcale of consent to s,If CE 8181280) APPLICATION FOR PERMIT
nisure or a cerufl ate Ot Workers Compensation Insurance or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec 3800 1 ab C)
Policy No Lompany
Certified cops Is h,rehy furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
department
copy w fled wllh the Lounn building msp,cliun FOR APPLICANT TO FILL IN BUILDING —
deparimen[
Dole Apph,ont (PRINT OR TYPE ONLY) ADDRESS
LOCALITY
CLRTII IC ATL OI EXEAIPI ION I ROM WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT FEE _
COMPENSATION INSUK 1NCI NEAREST
(This section need not be completed if dhe work involved ABSORPTION UNIT BTU CROSS ST 1
by the permit is for one hundred dollars (SI Oft or less) DISTRICT NO PROCESSED BY U
1 ccrtafy that In lh, prr(orman at u. work r hrah this AIR HANDLING UNIT CFM
cc
permit Is Issued I shall nm plo, an) p,rto n^ �) mnnner
O b,{ P�V subi,ct i the V dors Compen •tion Laths BOILER BTU APPROVALS DATE INSPECTORSISIGNATURE 0
Appl can, _ — COMPRESSOR BTU ROUGH
NOTILL TO APPLICANT I attLr making this C locale of VENTILATION SYSTEM
Ex,mpoon you S1101141h,ulmr suhj,et m t' .. Workers FINAL
Compensation pro"%ions of the Labor Coda you most forth EVAPORATIVE COOLER VALIDATION
vvnh comply with suLh provisions or this permit shall he
deemed revoked FURNACE FAU—_ GRAVITY
LICENSI D CONTRACTORS DECLARATION FLOOR BTU
I h,rebv affirm that ] am licensed under provisions of Chapter HEATER SU ' DED UNIT
9 (commencing w,th SLctiun 7000) of Division 3 of the Busi , k
ness and Professions COdL and my lions. Is In full IorcL and
effLLt
License NumbLr LO: Clas
Contractor Date
1 am exempt from the IICLnSmg requir,men[s as 1 am a
licensed mchltLct Of a fLgrotefed professional Lnguieer Plan cheek fee 25% of above
actml, In my professional CapaLoy (Section 7051 Bus
mess nid Prof,ssions Code) PERMIT ISSUING FEE $ 9)
LLC or Reg No DatL TOTAL FEE }}
HOME OWNER BUILDVR DEC LARATION PLAN CHECK APPLICANT
] h,rebv affirm that ] am Exempt from thi- Contractor s NAME
Llcens, Law for the follow,ng reason (S,ction 7031 5 Bust
n,ss ind Professions Code) ADDRESS
I as owner of the property will do lhL work and th,
�0753A
structure Is not unend,d or Offered for sale (SLLlien CITY TEL NO # • • • •i• 8
7044 Busmess and Professions Cud,) — [
ove
1 as Own,r of thL props[) am exclusivLly contracting - 205 0
with hc,nsed Lontri,tors to construct th, project N• .IL ( s
(Section 7044 Busin"s and Prof,ssions Cod L) .DDr�=� _3 f .• • 5
2 0 5 0
CONSTRUCTION LENDING AGENCY ; TEL NO o 'J 2;6—84
1 h,reby affirm that there 6 a Lonstructlon leadmg ag,ncy
for Ih, performanLL of the work for which this permit is CONTRACTOR
Issued (SLc 3097 Civ C )
Lenders Name ADDRESS
Lender s Address CITY TEL NO
1 certify that I hose read this application and state that the STATE LIC
abuvL Information Is correctague to comply with all Count, LICENSE NO CLASS
ardor s and Sta[L law a ularmg Hating Ventilating and
A wndl Inning and h m authunro repruen lollves of [h6 SLE RLVERSF I OR LXPLANATORY LANGUAGE
county I ,nor up t L above menlluned prop,ny fur 7//'
gnomic of Perml ice Uote /