HomeMy Public PortalAbout6353-6353 1/2 TEMPLE CITY BLVD_Mechanical__ W'ORKLRS'CONIPLNSATION DECLARATION CE 81C APPLICATION FOR PERMIT
1 hereby affirm that I have a certificate of consent to self CE 87812801
Insure or a certificate of Workers Compensation Insurance or HEATING-VENTILATING-AIR CONDITIONING
a At.f�rrr(dJ�c2v ryt gc 3800 Lab
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❑ CertdlLd copy Is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAF
(-Certnfled copy Is filed with the county budding Inspection FOR APPLICANT TO FILL IN BUILDING
depar a 1.�. ,1,� R TYPE ONLY)
AbD RESS ,'3- a53/Z. �l4(Ql�jYpC..r
Udh = Apphcan[_�IW_IA _bl (PRINT OLOCALITY /
CF RTII ICATE OF EXEMPTION FROM WORKERS' NO TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPLNSATION INSURANCE NEAREST NEAREST d
(This section need not be completed if the %Ork Involved ABSORPTION UNIT BTU
by the permit Is for One hundred dollars ($108) or less) DISTRICT NO PROCESSED BY 8
I certify that to lhL performance of the work for which this AIR HANDLING UNIT CFM s� �� it
permit Is Issued I shall not employ any person to any manner O
so as to become subject to the Workers' Compensanon Laws BOILER BTU
APPROVALS GATE INSPECTOR SSIGNATURE
Date Applicant COMPRESSOR BTU_ 7i_(U-Ya— Lam/ ' W
ROUGH
NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM FINAL �`V� Z
Exemption you should become subject to the Workers
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VALIDATION
with Lomply with such provisions or this permit shall be
deemed revoked FURNACE FAU� I Y 1
LICENSED CONTRACTORS DECLARATION FLOOR BTU _
I hereby affirm that 1 am licensed under provisions of Chapter HEATER SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Busl WALL
ness and Professions Code, and my license Is in full force and
effect / � 7
LicenseNu�mhyer3.2.60�f�2 G
Lie Class -Z0p (� 1J.7
Contractor R„d l/—�_ Data_/_
❑ 1 am exempt from the licensing requirements as 1 am a
licensed architect or a registered professional engineer Plan Check fee 25%of above
acting In my professional capacity (Section 7051 Bus
(ness and Professions Code) PERMIT ISSUING FEE $
Lie or Reg No Date TOTAL FEE 4
HOME OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's NAME
License Law for the Following reason (Section 7031 5 Bust
ness and Professions Code) ADDRESS
❑ I as owner of thL property will do the work and the • 3 7 0 9 A
CITY TEL NO
structure Is not Intended or offered for sale (SLLIIon C
7044 Business and Professions Code) # �'• 4
OOWNER
1 as owner of the property am exclusively contracting
project
rop • # 4700
with licensed contractors to construct the projectct MAIL
(Section 7044 Business and Professions Code) ADDRESS ��_ �+ - 47005
CONSTRUCTION LENDING AGLNCY CITYCw-/ /_�- - TEL NO �f -7--977. O 1 12-81 2_81
1 hereby affirm that therL Is a construction ILndm¢ agency vv��'�r'�/ CP77�j- !�7 IL
for the performance of the work tot which this permit Is CONTRACTOR d
Issued SSec 3097 Co, C ) - T
Lenders Name ADORE SSFjsZ3
Lender s Address CIT YY [TEL r9NrO
I certify t have read his Ipplmation and state that the STATE 'V^mow LIC
above In rtm Ion Is torr t I agree to comply with all County LICENSE NO 7 CLASS
Ord ccs a d tate 1^ . regulating Heating Ventilating and
Alr C m tit t and reby authorize refnC%Lnlahves of this SEE REVERSE I OR EXPLANATORY LANGUAGF
Cot Il t 1 r 1 I the above mentioned property for
uts t up
Signature of Permtttee Date liVa'