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