HomeMy Public PortalAbout6351 TEMPLE CITY BLVD_Mechanical__ WORKERS COMPI NSATION DECLARATION 76A364C APPLICATION FOR PERMIT
I hereby affirm that 1 have a certificate of consent to self
CE 818 (2 80)
insure or a certificate of Workers Compensation Insurance or HEATING-VENTILATING-AIR CONDITIONING
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El Certifnd cop} is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAAJT ix f/
02-1�ceD dmd copy u filed with the count) building " pec FOR APPLICANT TO FILL IN ADDRESS zz �}��� /�'7�►) J 1
d er me�pt �r I�--�' JSI lM-
Uatc_�_ =Q�_ Applaanl�LS�fh- (PRINT OR TYPE ONLY)
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CERTIFICATE OF EXEMPTION FROM WORKFRS NO TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST }
(This Section need not be completed If the work Involved ABSORPTION UNIT BTU CROSS ST d
by the permit Is for One hundred dollars ($IO0) or less) DISTRICT p0 PRDCESSED v -
1 certify that in the performance of the work for which this AIR HANDLING UNIT CFM -5-, 0j,eGj,
permit is issued 1 shall not employ any person In any manner O
so as to become subject to the Workers' Compensation Laws BOILER BTU InVVVt
-a 'l APPROVALS DATE sPECVOR 55IGNATURE aW
Date Applicant / COMPRESSOR BTU r/ 2_ � U
ROUGH 3L� ('f2p. " 4- y
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL �(O- z
Exemption you should become subject to the Workers
Compensation prmisions of the Labor Code you must forth EVAPORATIVE CO LER VALIDATION
with Comply with such provisions or this permit shall be
deemed resoked / FURNACE F A U rAV TV—
LICFNSED CONTRACTORS DECLARATION I FLOOR
1 hereby affirm (hat I am licensed under provisions of Chapter HEATER SUSPENDED UNIT
9 (commencing with Section 7000) of Dislsion 3 of the Bust WALL
ness and Professions Code and my license is In full force and
effect 2rpjjs!���1s pp[[�� /1�q�
L cense Number 3C A"- -89 Luc Class—C--90—
Lon
Lon tract or0t A Date_t_�I -151.
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engmecr Plan check fee 25%of above
acting in my professional capacity (Section 7051 Bus
mess and Professions Code) PERMIT ISSUING FEE $ '-
Lie or R_eg No Date TOTAL FEE Z ( '—
HOME OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affurm thit 1 am ex.mpt from the Contractors NAME
s License Law for the fallowing reason (Section 7031 5 Bust
ness and Professions Code) ADDRESS
1� I as owner of the property will do the work and the
structure is not untended or offered for sale (Section CITY TEL NO 3 7 Q 8 A
7044 Business and Professions Code) ������e,,
r--t OWNER JA_AK-EN4�CFS�-W i # *i� rr 41
u I, as owner of the property am exclusively contracting
with licensed contractors to construct the project MAIL nn
(Section 7044 Business and Professions Code) ADDRESSCIC- 2 • - 27.00
CONSTRUCTION LLNDING AGPNCY CITY �,�.Q D.� TEL NO -s pO�G�7.f �� 27005,, O O V
1 hereby affirm that there Is a construction lending agency CONTRACTOR V F' s- �L =1
for the performance of the work for which this permit is
issued(Sec 3097 ew C) dIA_M�3A►�_ _�_rT— 01 1 2-81
Lender s Name ADDRESS?..�2_CWT' EL
Lender s Address / J �.r_ ^li
CITY s �-t TEL NO /I il��ilGyal_
1certify hat 1 hale r d this application and state that the STATE LIC
It k mesion Is roe[ I agree to comply with all County LICENSE NO 2 CLASS G ZO
ordt nee an Stat ws regulating Heating Ventilating and
Air _r n ba i g ai hereby suthon/e representatives of this SEE REVERSE FOR LXPLANAI ORY LANGUAGE
Ca .n y to c der nn the abuse menttuncd property for
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SI Lure of Permittee Date