HomeMy Public PortalAbout4930 ROSEMEAD BLVD_Mechanical__ • WQRKFq° -COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, - VE- VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C
CE-818(REV. 10/81)
Policy No. Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS ►l
Date Applicant LOCALITY r� �
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. 4& 1 g.
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars ($100)or less.)
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 BOILERBTU
so as to become subject to the Workers' ompensati n LOWS. , APPROVALS DATE INSP TOR'S SIGNATU E
L
�6\ COMPRESSOR; BTU ROUGH +
Date L pplicant
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL _ /
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDAT ON
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
HEATER:
(commencing with Section 7000) of Division 3 of the Business WALL o0
and Professions Code,and my license is in full force and effect.
O
License Number Lic. Class ,
Bt
Contractor Date O
r�
❑ I am exempt under Sec.
Plan check fee 2 8 1 7.9 A
B.BP.C. for this reason' # o:o o.a;® 8
PERMIT ISSUING FEE $ Q �� I o 0
Date: 20,50
S S
Signature TOTAL FEEo 0 0 2 Q 5 O,(—J
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT q
I hereby affirm that I am exempt from the Contractor's License ( 2 3 '8 7
Law for the following reason (Section 7031.5, Business and NAME , 0
�
Profe sions Code):
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,wiII do the work and CITY TEL. NO.
the structure is not intended or offered for sale(Section
7044, Business and Professions Code).
OWNER �--
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project*(Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS Zf�/
'7 6
CONSTRUCTION LENDING AGENCY CITY TEL. NO.? S—
I hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
CITY TEL. NO.
Lender's Address
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby author' a representatives of this County to.enter
upon the above- tioned p perty for inspection purposes. SEE REVERSE,FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date