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HomeMy Public PortalAbout6360 TEMPLE CITY BLVD_Mechanical__ ' WORKER I have a c@SATIONOEConsent to 20a0saDP1V°r8a APPLICATION FOR PERMIT LIME GREEN I heJeby affirm that I have a certdiCate of consent to Calf Insure ]aA381C or a certificate of Worker a Compensation Insurance or °certified copy thereof(Sec 3800 Lab C HEATING-VENTILATING-AIR CONDITIONING ) Polley No AVRen Ca COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV lf��a6pu,J(( CeMled copy is hereby furnished Certified copy 13 flied with the county building Inspection FOR APPLICANT TO FILL INS 3� /J (PRINT OR TYPE ONLY) _ Data IlatttL�� �/ �wi( NO TYPE OF APPLIANCE OR EOIAPMENT FEE LOCALITY / CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST , COMPENSATION INSURANCE CROSS ST ABSORPTION UNIT,BTU n ASSESSOR on (This section need not ed completed(31 N fwort Involved Dy ttheMAP BOOK PAGE PARCEL permit Is for o hundred dollars ft lou) AIR HANDLING UNCFM s I certifycertifythat In the performance of thehe or or u work for which this permit DurmIcr in Is issued I shall not employ any person in any manner for as to BOILER BTU o become subject to the Workers Compensation Laws �QQ COMPRESSOR BTU Date Applicantrsneovus wit eiaow,n VENTILATION SYSTEM NOTICE TO APPLICANT a after making this Certificate of ROlX3N Exemption you should Lab became yublaol to the Workers Compensationwithssuch provisions of the Labor Code you must forthwith comply with such EVAPORATIVE COOLER FINAL provisions or permit shall RLFURNACE FALICEECOTRCTOSDECLARATION FLOOR U B1U 000 G d VALIDATION I hereby affirm that 1 am licensed under provisions of Chapter 8 SUSPENDED—UNIT— (commencing USPENDED UNIT_(commencing with Section 7000)of Division 3 of the Business and HEATER WALL Professions Code and my license is In full force and effect License Numbel(�(, Lk Class � V Y 6 a Contract O ❑ I am exempt under Sec Plan check fee B&P,C for this reason PERMIT ISSUING FEE S S �':17 i r 1. ¢O Signature °e° TOTAL FEE TOTAL 171 v 37 a OWNER BUILDER DECLARATION PLAN CHECK APPLICANT 171. Z I hereby affirm that I am exempt from the Contractor a License Law NAME for the following reason (Section 7031 5 Business and Professions Code) ADDRESS ❑ I as owner of the property or my employees with wages as their sole compensation will do the work and the CITY TEL NO structure Is not Intended w offered for ule (Section 7091 Business and Professions Code) OWNER ❑ I as owner of the property am exclusively contracting MAIL with licensed contractors to construct the project (Sec ADDRESS UM 7094, Business,and Profesalons Code) CONSTRUCTION LENDING AGENCY TEL I hereby affirm that there ie a construction lending aGency for CONTRACTOR pop. (Sao performance of the work for which this permit is Issued (Sao 3087 Civ C I ADDRE99 Lender a Name C TEL /F7k D Lender a Address US I certify that I have read this application and state that the above LX:1 8E L CLASS information Is correct I agree to comply with all County ortllnanoes and State laws relatmg to building consinwbon,and hereby aulhonze represeMalwas of this County to enter upon the abov entioned property nepec on pu gees L SEE REVERSE FOR EXPLANATORY LANGUAGE on mif DAre