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HomeMy Public PortalAbout6350 TEMPLE CITY BLVD_Mechanical__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affrcm that 1 have a certificate of consent to self lrcor a if ed cocertificate thereof (SecWorkers' 3800 LabCompensation Insurance oraert7eA364C HEATING - VENTILATING - AIR CONDITIONING Py ) CE 818(REV 10/81) Policy No Company Certified copy is hereby furnished COUNTY OF LOS ANGELES_ BUILDING AND SAFETY ❑ Certified copy is filed with the county building inspec FOR APPLICANT TO FILL IN BUILDING nADDRESS C>��SQ on department (PRINT OR TYPE ONLY) Date Applicont LOCALITY T �� NO TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST COMPENSATION INSURANCE CROSS ST (This section need not M completed if the work Involved by ABSORPTION UNIT BTU DISTRICT NO RR Y the permit Is for one hundred dollop ($100)or less ) b 1 I certify that In the performance of the work for which this AIR HANDLING UNIT CFM permit Is Issued I shall not employ any person In any manner jSOILER BTU z so as to become subject to the Workers Compensates AP VALS DATE1N*01t S SIGN R Dat IIcant COMPRESSOR BTU ROUGH NOTICE TO APPLICANT If after ma mg this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code you must forth- EVAPORATIVE COOLER VALIDATI with comply with such previsions or this permit shall be deemed revoked FURNACE I G VITY ' LICENSED CONTRACTORS DECLARATION FLOOR BN I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED—UNIT— (commencing USPENDEDUNIT_(commencing with Section 7000) of Division 3 of the Business WALL and Professmre Code and my license Is In full force and effect d License Number / J?[�G be Class 5 —,110 , {Oj K Contractofo//�� "Date� O Elam exempt under Sec W Plan check fee us B 8P C for this reason us = Dore PERMIT ISSUING FEE $ D Signature TOTAL FEE OWNER BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor s License Law for the following reason (Section 7031 5, Business and NAME Professions Code) ❑ 1, as owner of the property or my employees with ADDRESS wages os their sole compensation will clothe work and CITY TEL NO the structure Is not Intended or offered for sole(Section 70" Business and Professions Code) OWNER ;F 8 6 9, 9 A ❑ I as owner of the property am exclusively contracting • • • • • 8 with licensed contractors to construct the project (Sec MAIL / _ �/ # non 7044, Business and Professions Code) ADDRESS J` �� I is 2 Q J Q CONSTRUCTION LENDING AGENCY CITYy�� ��f TEL rp /��Da73r = I hereby affirm that there Is a construction lending agency for •C • 2 Q Jr Q 6 the performance of the work for which this permit Is Issued CONTRACT , (Sec 3097 Civ C ) a 6 u 1231 -: 87 ADDRES — Lender s Name �1 Lender s Address CITY /Sl�� .C7<Z L NO � . I certify that I have read this application and state that the UaNSE _7p &C SS 5 above mformahon Is correct I agree to comply with all County ordinances and State laws relating to building construction and hereby authorizer entateves of this County to enter ' upon bove me property for ///(Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE r Signature of Applicant a Agent Date WORKER I have a certificate DECLARATION 700D1e DPW 8188 APPLICATION FOR PERMIT LIME GREEN 7DOW I hereby affirm that I neve a certlftceie of consent to self Insure or a certificate of Worker a 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 ❑ CeNfied copy is hereby furnished ❑ Cemhed copy la filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING C 7\ department (PRIM OR TYPE ONLY) Date Applicant L OCO NO TYPE OF APPLIANCE OR EOUIPMEM FEE CERTIFICATE OF EXEMPTION FROM WORKERS N sT ST COMPENSATION INSURANCE ABSORPTION UNIT BTU (This section need not be completed H the work Involved by the PPAGF�� PARCEL permit to for one hundred dollars($100)or leu) AIR HANDLING UNITCFM Peau ey 1 certify that In the performance of the work for which this permit Is issued I shall not employ any person io any manner so as to BOILER BTU become subject to the Workers Compensation Laws 7 COMPRESSOR BTU ion u�roas ebruT Data Applicant VENTILATION SYSTEM NOTICE TO APPLICANT If after making this Certificate of EVAPORATIVE COOLER POucq Alp' Exemption you should become subject to the Workers Compensation provisions of the Labor Cade you must forthwith comply vnth such Fl 4. provisions or this permit Shell be deemed revoked FURNACE FAU �t, LICENSED CONTRACTORS DECLARATION FLOOR BTU 0 4 ) VALIDATION affirm C I hereby arm that I em licensed under provisions of Chapter 9 SUSPENDED UNIT_ -1 (commencing with Section 7000) of Division 3 of the Business and HEA Professions Code and my license is In full force and effect License Number LJc Clens �/OS-G.c- ACiT.i } 3�G� ts`'.� Contractor Date ❑ I am exempt under Sec Plan check tee I ITEME B AP C W this reason PERMIT ISSUING FEES cc Q TOTAL 85 _ 8 O Date CHEiY, c5.°I]v TOTAL FEE �0 !C�11J t�� Alrtawre PUN CHECK APPLICANT nAtK]L .Vl. N OWNER BUILDER DECLARATION Z I hereby affirm that I em exempt from the Contractor a License Law NAME �t1, forthefollowing reason (Section 7031 5 Business and Professions L— , UGlll—I]I]QI ?1Ic f�� st AGGRESS f as owner of the property or my employees with wages O�W � c IT Gh� I AM 7%Y� as their sole compensation will do the work and the CITY structure to not Intended or offered for sale (Section 7044 Business and Professions Code) OWNER ❑ I as owner of the property am exclusively contracting MAIL with licensed contractors to construct the project (Sec ADDRESS hon 7044 Business and Professions Code) CONSTRUCTION LENDING AGENCY CRY TEL NO I hereby affirm that there lea constructionwhi this s permit agency for CONTRACTOR the r performance affirm t of the work for which Inas permit Pa Issued or yw�K�V (Sec 3087 CN C) ' ADDRESS Lender a Name CRY TEL NO Lendw a Address STATE LIC I cert11had this eppl¢atton entl erste that the above LICENSE NO CIaSS lorI agree to comply wnh ell County ordinancesend Sto building construction,end hereby authonxe repreCounty to enter upon the above,menbo ted propn purposes 3_ SEE REVERSE FOR EXPLANATORY LANGUAGE LIE OF OA AGENT � '� WTE