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HomeMy Public PortalAbout6357 TEMPLE CITY BLVD_Mechanical__ WORKERS COMPENSATION a ONDICLARATION CE 81 C APPLICATION FOR PERMIT I hereby affirm that 1 have a cutif7cnte of consent to salt CE 918 (2 80) Insure or a certificate M Workers Compensation Insurance or HEATING-VENTILATING-AIR CONDITIONING ^ -zomyAcl. e tpW� yf i P0 � C ❑ L<rttfted copy Is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY u Cc lifted cop) u filed with the count) budding Inspection BUILDING FOR APPLICANT TO FILL IN Date _ ApphcenlN,W�A CILI?�– (PRINT OR TYPE ONLY) ADDRESS �as1 r _ _ems LOCALITY CLRTI FICATE OF EXEMPTION f ROM WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT FEE COMPLNSATION INSURANCI NEAREST r (This Section need not be completed If the work tttvolved ABSORPTION UNIT BTU CROSS ST d by the permit is for one hundred dollars (5 100) or Icss) DISTRICT NO veocessro ar 1 certify that In the performance of the work for which this AIR HANDLING UNIT CFM o�' fl permit Is Issued 1 shall not employ any person in an} manner Q sit as to become subject to the Workers Compensation Laws BOILER BTU 000 �/`� APPROVALS DATE INSPECTOR S SIGNATURE Date Applicant COMPRESSOR BTU_Z f'L.�QA�S— al-/ r ROUGHj/` NOTICL TO APPLICANT If aft<r making this Certificate of VENTILATION SYSTEM O Z 1 xemption you should become subj<ct to the Workers FINAL (t7 Compensation provismns of th< Labor Code You mutt forth with comply with such provisions or this permit shall he EVAPORATIVE COOLER VALIDATION deemed revoked FURNACE FAU G AVITV ID 7 C LICENSLD CONTRACTORS DLCLARATION FLOOR BT 60,CW— I hereby affirm that 1 am licensed under provisions of Chapter HEATER SUSPENDED UNIT 9 (commencing with Section 7000)of Division 3 of the Bost WALL ��� ness and Professions Code and my license Is In full force and effect q����pp�� rj�� Licens<Number37-37 - Lic Class C-w - Contra<tor/-44//,ry_Vargf_ Date_/=moi 81 ❑ I am exempt from the hc<mmg reymrem<n[s as I am a licensed architect or a r<gistered professional engineer Plan Check fee 25%of above acting In my professional capacity (Section 7051 Bus inessand Professions Code) PERMIT ISSUING FEES '1 Lie or Reg No Date TOTAL FEE 22-7 DO HOME OWNLR BUILDER DECLARATION PLAN CHECK APPLICANT 1 hereby +ffrm that I am ex<mpt from the Contractors NAME License Law for the following reason (Section 7031 5 Bust nus and Professions Code) ADDRESS ❑ 1 as owner of th< properly will do the work and th< 3 7 1 1 A struclur< I5 not intended or offered for sale (Section CITY TEL NO 7044 Business and Prof<sstunsCode)❑ OWNER r �� • 41��/ //H1rJ i�d/_ !e /mss I as owner of the property nm <x clumvely contracting with licensed contractors to construct the project MAIL 2i• • 27.00 (Seaton 7044 Business and Professions Cody ADDRESS CONSTRUCTION LENDING ALF NCY CITY,,5 ��S�f��L TEL NO ? 70 �. X2700�$ I hereby affirm that there is a construction lending agency e? t 01 1 2—8 1 for the performance of the work for which this permit is CONTRACTOR/JH/A /_ /IG4 4Z� I� Issued (Sec 3097 Civ C) MCe/ /`7G� I end<r s Name ADDRESS Z5 C�r� Lender 5Address CITU/'—v /-0�� TEL NO 1 cerlif) that I have r<ad [ application and state that the STATE LIC aboxe mfor Ion Is curt" agree to comply with all County LICENSE NO CLASS jy0 ordmanc , a d St a law -gulating H<atmg Ventilating and Ao Cot Jin ling nd h iy authoriz< repres<ntatnes of this SLP REVLRSE I OR EXPLANATORY LANGUAGI, Count ent u he abose m<nnoned propert) for ntspe I ourl C Signa ore of ermtitee Date