HomeMy Public PortalAbout5423 ROSEMEAD BLVD_Mechanical__ WERSr COMPENSATION DECLARATION APPLICATION FOR PERMIT
t hereby a' IrRKm than I have d certificate of consent to self
insure: or.,a certificate 6f Workers' Compensation Insurance, HEATING - 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. ADDRESS
(PRINT OR TYPE ONLY) �/
Date Applicant LOCALITY �/
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
CESSED BY
BTU DISTRICT NO. ® P
(This section need not be completed if the work involved by ABSORPTION UNIT, t
the permit is for one hundred dollars ($100)or less.)
AIR HANDLING UNIT, CFM
I certify that in the performance of the work for which this A / /� (`�/')/�
permit is issued, I shall not employ any person in any manner BOILER, BTU i5 ��"�Q/ ``� `�
so as to become subject to the orke s'Compensation Laws. AaPRovals DATE nysa cT, 's siGNnT RE
COMPRESSOR, BTU V ROUGH
Date' ��'APplicanT jjj /�
NOTICE TO APPLICANT: If, after ma ing this , rtif!cate of VENTILATION SYSTEM/0 FINAL
Exemption, you should become subject to t e Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N
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 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. IL
7
License Number Lic. Classes ' U
Contractor
Sf P iy1C Date s. 9U,' . 1257 0
❑ I am exempt under Sec. LU
V
Plan check fee
a
6.8P.C. for this reason' x.7.7 5.2
Date: A
PERMIT ISSUING FEE $ #',o 0 0 ® o $
TOTAL FEE
Signature g a ® 4Q50
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
1 hereby affirm that I am exempt from the Contractor's License e o - 4 O 5 O,H
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I,. as owner of the property, or my employees with ADDRESS Q 2 6 7
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CIT I TEL. NO 'q
7044, Business and Professions Code). c `
OWNER 0 9
hr-
El I, as owner of the property, am exclusively contracting r
with licensed contractors to construct the project (Sec- MAIL J
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY C I TEL. NO. 1i —K✓ u
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.). f V,C.
ADDRESS fAI bles
Lender's Name
CITY _ �� TEL. N '1_7Lender's Address
STATE LIC. /..
I certify that I have read this application and state that the LICENSE NO. 3� CLASS,
above information is correct. I agree to comply with all County
ordinop'..kesk and State laws relating to building construction,
and h authorize representatives of this County to enter
pq�, t ove-mentioned propert ,or in ct! n pur s. SEE REVERSE FOR EXPLANATORY LANGUAGE
�- In n
Signature of Applicant or gent Date ((••,,✓✓