Loading...
HomeMy Public PortalAbout5018-5026 ROSEMEAD BLVD_Mechanical__ WORKERS' COMPENSATION DECLARATION UYU1 zs APPLICATION 'FOR PERMIT 1 hereby affirm that-I have a•'certificate,of consent to,self 1� -r � I?� inswe, or a certificate of Workers' Compensation Insurance, 4 {J HEATING - VENTILATING - AIR CONDITIONING ,fir a certified copy thereof (Sec. 3$00, Lab. C.) 76A364C / �� � ��� 20-0046 DPW 9/88 Policy No. Company ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY (Certified copy is filed with the county building innspec- FOR APPLICANT TO FILL IN BUILDING tion department. /A (PRINT OR TYPE ONLY) ADDRESS Date —7 4112 Applicant/"'6u LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCEVSQ 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 so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DYE INS ECTOR'S iGNATURE Date pplicant COMPRESSOR, BTU 2-4rc>�s� ROUGH A + 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 V with comply with such provisions or this permit shall be deem- ed revoked. FURNACE: FAU V LICENSED CONTRACTORS DECLARATION 60 FLOOR BTU �- 1 hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business WALL. and Professions Code,and my license is in full force and effect. 2 333 G—z� d License Number Lic. Class , O Contractor [a!3 oe nate O ❑ • I am exempt under Sec. 11-- Plan check fee u W B.&P.C. for this reaso H PERMIT ISSUING FEE $ Z Signature TOTAL FEE OWNER-BUILDER DECLARATI PLAN CHECK APPLICANT I hereby affirm that I am exempt from the ntractor's License Law for the following reason (Section 1.5, Business and NAME NIIII Professions Code): u F-1 1, as owner of the property, ADDRESS or my employees with ,• wages as their sole compensation, will do the work and CITY TEL. NO. CDCT.3O the structure is not intended or offered for sale(Section ��r� -, �- 7044, Business and Professions Code). ..t,.07 130.50 ❑ OWNER 1 T I, as owner of the property, am exclusively contracting �'L{�- N1• 0 `A/ 1 ITEMS with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESSL/� 15I -vT�'�� ' TOTAL 130 . 50 CONSTRUCTION LENDING AGENCY CITY TEL. NO. -Z,2 hereby affirm that there is a construction lending agency for Nib ��4— ��'� 11310.50 the performance of the work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C.). Pilo. CHANGE .011 ADDRESS2— lL� I A& Alk Lender's Name -t-}�S_ '-y�y CITY /tNC� TEL. NO. IJIJUI.J`0100l 11�' 9/39 Lender's Address v l I certifythat I have read this application-and state that the STATE �� LIC. 667�j 1 AM 9e-y LICENSE NO. CLASS �2 � ��'�' above inf m tion is correct. I agree to comply with all County ordina e 4d State la/Ns relating to building construction, ' and hrq6y u ori ze presentatives of thi County to enter' upon t - n ned property for ins ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or ent Date ©s WORKERS' COMPENSATION DECLARATION UAR�� APPLICATION FOR PERMIT on'Insurance, I hereby affirm that._1 have a certificate of consgnt to self /�"� -7 insure, or a certificate of Workers' Compensati �� t HEATING - VENTILATING - AIR CONDITIONING or a certified`copy thereof (Sec. 3800, Lab. C.) 76A364C d t(2C� S-,71 20-0046 DPW 9/88 olicy No.�CompanyrS T-V ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certifiep copy is filed with the county building ius ec-� FOR APPLICANT TO FILL IN BUILDING . r tion department. ADDRESS L� L (�/� (PRINT OR TYPE ONLY) Date rG -Applicant '- �� �" LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PR ESSED BY . the permit is for one hundred dollars ($100) or less.) (�/7 I certify that in the performance AIR HANDLING UNIT, CFM of the work for which this �s permit.is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date. Applicant COMPRESSOR, BTU 2AICOO Q V ROUGH 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 A v j with comply with such provisions or this permit shall be deem- ed revoked. FURNACE: FAU RAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business WALL and Professions Code,and my license is in full force and effect. 2'33 3 � License Number 1Lic. Class , d O Contractor 14LE0 4/4.0 A)2)• Date — oe ❑ I am exempt under Sec. O Plan check fee u W B.&P.C. for this r sort. H PERMIT ISSUING FEE $ Z Signature TOTAL FEE OWNER-BUILDER DECLAR ION PLAN CHECK APPLICANT I hereby affirm that I am exempt from't4 Contractor's License Law for the following reason (Section 7031.5, Business and NAME Professions Code): I, as owner of the property, or my employees with ADDRESS wages as their sole compensation, will do the work and AC -Tns NO. the structure is not intended or offered for sale(Section CITY TEL. �± c 7044, Business and Professions Code). OWNER 113s7 150.5 0 ❑ 4 I, as owner of the property, am exclusively contracting J,)--�L � I iTEM-:; with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESSI.Iit� � �® tom CONSTRUCTION LENDING AGENCY CITY TEL. NO 0 L� �2 — `c�1- C-HECK 150.510 I hereby affirm that there is a construction lending agency for the performance•of the work for which this permit is issued CONTRACTOR t�l& `�� �; o (Sec. 3097, Civ. C.). poll ADDRESS Lender's Name , 0006 �•yy �,�•�� {{. CITY !- l�r TEL. N0. 3�4 V tl -00r 1lt, 7jv Lender's Address C I certify that I have read this a lication and state that the STATE' LIC. Z 5675 f AM 1yo;-9 Y PP LICENSE NO-512-3'o3,95CLASS above i rmation is correct. I agree to comply with all County .,dinand State laws relating to building construction, and re y authorize epresentatives of this County to enter up ih ar toned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE l(- q 45 Signature of Applicant or A nt Date ©s