HomeMy Public PortalAbout6424 TEMPLE CITY BLVD_Mechanical__ WORKER S COMPENSATION DECLARATION 204M DPW 9/89 APPLICATION FOR PERMITLIME GREEN
I hero* affirm that 1 have a certificate of consent to self Insure 784364C
or moor ff cate of Worker a hompeneahon Insurance or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec 3800 Lob C)
Policy No I�—• T"y `ECOUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
ElCaroled copy is hereby furnished '
❑ CeniBed copy Is filed with the county building inspection FOR APPLICANT TO FILL IN IwILdNG �C MP�C� BL�/�
tlepenmenl (PRINT OR TYPE ONLY) ADDRESS j� n
Date Applicant LOCALITY PLS C/!
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE 3 7-.J CROSS ST
(This section need not be completed It the work Involved by the ABSORPTION UNIT BTUASS ESMAP BOOK
PAGE PARCEL
permit Is for one hundred dollars($100)or Inas I AIR HANDLING UNIT CFM
oemcr ao evacsssco BY
I certify that in the performance of the work for which this permit 1902
Is Issued I shell not employ any person In any manner so es to BALER BitIftom
�y(-/
became subject to the Workers Compensation Laws d.l cc
COMPRESSOR SITU
Date Applicant .s W, DAM u�ecroa6doru
VENTILATION SYSTEM
NOTICE TO APPLICANT If after making this Certificate of ROUGH
Exemption you should became subject to the Workers Compensation EVAPORATIVE COOLER
Provisions of the Labor Cade, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked / I FURNACE FAU GRAVITY VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR B
I hereby affirm that I em licensed under provisions of Chapter g NI
SUSPENDED UT_
(commencing with Section 7000)of Division 3 of the Business and
HEATER WALL
Professions Code and my license Is In full force and effect
LTcerme Number Zam,412
Lic Close Q
e
�J T
Comractor M, r nwa- Date AC C T.i Q
❑ I am exempt under Sec Plan check fee ' 33307 113.3 U
Q
B 8P C for this reason PERMIT ISSUING FEE$ 7 1 ITEMS of
Dela TOTAL FEE I 3 �iT TOTAL ' 113_ 38 w
Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT CHECK 119.-i. U)
I hereby affirm that I em exempt from the Contractor a License Lew NAMEMftNUGL • �J/ Pill,for the following reason (Section 7031 S, Business and Professions
Com) ADDRESS
❑ I as owner o1 the property or my employees with wages 02 IJ
013110-LO3131 12/ 7/52
as their sole compensation will do the work and the CITY `'� TEL fa0
structure is not Intended or offered for sale (Section 7044 y 6595 1 AM 10R 11
Business and Professions Code) OWNER b`p v L3HG
❑ I as owner of the property em excluelvely contracting
with licensed contractors to construct the project (Sec ADDRESS LV
tion 7044 Business and Profeasions Code) T^
CONSTRUCTION LENDING AGENCY CITY / C+ . TEL NO
1 hereby anon that there is a constructionwhi this
sperlending apencs for
the performance of the work for which This permit 4s Issued CONTRACTOR
(Sec 3097 Civ Of
ADDRESS o2.i
Lenders Name
Cm 7'—G TEL NOt)Lj//�
Lender s Address, 1�
I Certify that I have read this application and state that the above CLIC a NO �Q,'3 CLASS (l
in ma
I cortect agree to compty wdh ell County ordmencee
antl State relat o il0ing conslruclbn end hereby eulhorae
topreeem es o n t emer upon the above mentioned
prop s BEE REVERSE FOR EXPLANATORY LANGUAGE '