HomeMy Public PortalAbout6355 TEMPLE CITY BLVD_Mechanical__ WORKERS COMPENSATION DECLARATION 7BA364C
I hereby affirm that I hale o certiKco[e of consent to self
CE B18 (280) APPLICATION FOR PERMIT
Insure or a certif""icat,of Workers Compensation Insurance or HEATING-VENTILATING-AIR CONDITIONING
a er It�dB/yy/yr�rfA3G 3800,lab CC'),r �I
Pohc)NoOv ver/CoompanyL�'G � t—
❑ CenIfn.d copy Is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
C_7n; copy S filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING 4.0 � y/O
de .v� IIp,^nJs/ ` ' /�J - ADDRESS �tTi1
Date Applicant_!�_ �( (PRINT OR TYPE ONLY) —
LOCALITY
CF RTIFICATE Of EXEMPTION FROM WORKERS
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST
(This welum need not he completed if the work Involved ABSORPTION UNIT BTU CROSS ST 0
by the permit Is for one hundred dollars (5100) or less) DISTRICT NO vROCEssr i By U
1 CerIIfy that in the performance of the work for Which this AIR HANDLING UNIT CFM—
permit
S
permit Is Issued I shall not employ any person in an, manner O
so as to become subject to the Workers Compensation Lass BOILER BTU U
^� �,�y� ./� APPROVALS DATE INSPLTORSSIGNATURE
Uate Applicant COMPRESSOR BTU —?66-" /V d
ROUGH I C+Vi.dJ Z y
NOTICE 10 APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL ���^ Z
Exemption you should become subject to the Workers
Compensation provisions of the Labor Code you must forth
with comply with such provisions or this permit shall be EVAPORATIVE COOLER VALIDATIOe.
deemed rexokod FURNACE FAUR VITY_
LICENSED CONTRACTORS DECLARATION FLOOR BTU_ 10 r/ r
1 hereby affirm that 1 am licensed under provisions of Chapter HEATER SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Bus, WALL
nes, and Profession, Code and my license Is in full force and �3
effect
License Numb/eer,99 99 Llc Class C 2O
ContractoDate/2-
❑ I am exempt from the licensing requirements as 1 am a
llcen A.d architect or a n.g,stered professional engineer Plan Check fee 25%of above
acting in my professional capacity (Section 7051 Bus
mess and Professions Code) PERMIT ISSUING FEES '7
Llc or Reg No Dote TOTAL FEE Z7 00
HOME OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
1 hereby affirm that I am exempt from the Contractors NAME
License I aw for the following reason (Section 7031 5 Bus,
nes,and Profession, Code) ADDRESS
❑ 1 as owner of the property will do the work and the TEL NO
structurL Is not Intended or offered for sale (Section CITU �9 317 1 0 A
7044 Busmcs,and Professions Code)
❑ I as owner of the OWNER /LL �fa-3t y��n// fl CQ # � (11
property am exclusively contracting (//f ��_.�J„ GL
with licensed contractors to construct the project MAIL
(SeLllon 7044 Business and Professions Code) ADDRESS QO5_51 2 2 7.0 0
CONSTRUCTION LENDING AGENCY CITYrg TEL NO r7G�_�7� 27. 006
I hereby affirm that there Is o construction Icndmg agency
for the performance of the work for which this permit is CONTRACTOR O -1 12-81
issued(Sec 3097 Civ C )
Lender s Name ADDRESS
Lender s Address CITY t !%VLG�C R�r TEL NO
I certify th have read t s apphc.1ion and state that the STATE -r lr. LIC
abo,e mf m ion s cora I agree to comVly „Ith all County LICENSE NO C.fv✓ CLA55 G-7G
ordman a Id c ro is regulating Heating Ventilating and
Au CI i mm and -by authorvc repres.ntatives of this SI E RFVERSI 1 OR EXPLANATORY LANGUAGF
Cour v er r r the above mentioned�property for
rasp �s I I Z (J
Signature of Permittee Date