HomeMy Public PortalAbout6439 TEMPLE CITY BLVD_Mechanical__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
?hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers Compensation InVopnce HEATING - VENTILATING - AIR CONDITIONING ,
or a certrfi c thereo Sec Lab )
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Policy N ompo I -
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certiftsfiled with the aunty b inspec- FOR APPLICANT TO FILL IN BUILDING
tion ADDRESS(PRINT OR TYPE ONLY)Date / ApplGan gq LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPT FROM WO NEAREST
COMPENSATION INSURANCE _ CROSS ST
• (This sedlon naafi not be compls,tad R fM work Invalvs,d by ABSORPTION UNIT eN DSTRICT NO PROCESSED By
the,parrrdt Is for ons,bundrad dollars ($100) or lass) r
I certify that in the performance of the work for which this AIR HANDLING UNIT CFM
permit is Issued I shall not employ any person in any manner
30 W to become subject to the Workers Compensation Laws BOILER BN l APPROVALS DATE INSPEcroR 551GNATURE
Date Applicant •� COMPRESSOR BTU ROUGH
NOTICE TO APPLICANT If offer making this Certificate of VENTILATION SYSTEM - Flrul
Exemption you should become subject to the Workers
with comply
w provisions vi the labor Code you must froth- EVAPORATIVE COOLER _ - PT*AN �=
with comply withsuch provisions or this permit shall he deem-ed revoked ' FURNACE F 'LICENSED CONTRACTORS DECLARATION FLOOR - BN
I hereby offnm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT
(commennng with Section 7000)of Division 3 of the Business WALL
and Professiorn Code;and my license rs in full fort and effect 1 8^
}
/7 d
License Nu S Lic Cla �" pop. V
Contractor a !� 7 _ 0
[II exempt under f 13Plan check fee LLE
B 8P C for this reason d
PERMIT ISSUING FEE $ 3 - H
Date Z
TOTAL FEE
Signature _ AGC T.i
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor s LicenseT 111110. "07 5-5.00
Low for the following reason (Section 7031 5, Business and NAME 1 ITEM° - I
Professions Code) 11 �y
I, as owner of the property, or my'employees with ADDRESS'-- TOTAL 515 � 00
wages as their sole compensation will do the work and CITY — - TEL NO CHECK 55.0[1the structure is not intended moffered for sole(Section
7044 Business and Professions Code) OWNER �rvusVL ,QI]
I as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec MAIL
ADDRE l
hon 7044, Business and Professions Code) lU g7'3[l
CONSTRUCTION LENDING AGENCY CITY TEL NO07 ,g
I hereby affirm that there is a construction lending agency for pop, � 1 AM1l:l]7
T
the performance of the work for which this permit is issued CONTRACTOR g -
(Sec 3D97, CN C )
ADDRESS - •- - t--_ - n
Lenders No -• - r - -- - -
CITYTEL
Lenders Address
TE
I certify that I have read this application and state that the uaNSE NO Q
DMC SS
above Information*correct I agree to comply with
ordinances and State laws relating to building construction
a eb author representatives of this County to nter
n v honed property fro mspe ion ses
SEE REVERSE FOR EXPLANATORY LANGUAGE
0 ure of Applican nt Doe QL