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