HomeMy Public PortalAbout5439 ROSEMEAD BLVD_Mechanical__ WORKER'S COMPENSATION DECLARATION 4 9/89
76A364C APPLICATION FOR PERMIT LIME GREEN
76A3
I,tereby affirm that I have a certificate of consent to self insure, (�
or a certificate of Worker's Compensation Insurance, or a certified HEATING- VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab. C.) LJ
Policy No. Company -� uv,,71 COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN' BUILDING
d partment.- f (PRINT OR TYPE ONLY) ADDRESS �/ �. /�• -,
LOCALITY
Date 2' Applicant N0. TYPE OF APPLIANCE OR EQUIPMENT ,FEE
CERTIFICATE OF EXEMPTION FROM WORKEX. NEAREST
CROSS ST.
COMPENSATION INSURANCE
1 .
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less,) AIR HANDLING UNIT,CFM
DISTRICT NO. PR CESSED BV
I certify that in the performance of the work for which this permit -e
Js issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws. i 1� �L,lg( 000 1 1,%t UC? !/O
"t COMPRESSOR,BTU ((]
APPROVALS DATE INS P TOR'S SIGNATURE
Date Applicant '7 VENTILATION SYSTEM 70
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'CompensationEVAPORATIVE COOLER -410provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. L FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION ` FLOOR , p VALIDATION ,-t•;
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPE D iti : UN
(commencing with Section 7000) of Division 3 of the Business and A HEATER: WALLICS 0 1•'f I-°= 7'4
Professions Code,.and my license is in full force and effect. a �,
t,
'A
i
License Number `S5 , Lic.Class —0
2 CL
Contractor:l on�.v\ Date t{- �~
❑ I am exempt under Sec. Plan Check fee - ° I=`
B.&P.C.for this reason PERMIT ISSUING FEE$ '� TOt` - ..°`` O
Date: TOTAL FEE ,.HLY„•r+• ±�'r•�°_= W
CL
Signature ',IHS 1t t
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions ' ;�1 {{�I-i l_hi 5/Z-.)1
Code): ADDRESS
❑ I, as owner of the property, or my employees with wages --
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER
❑ I; as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS 3 I r stn A �C
tion 7044,Business and Professions Code)., �)
CITY i}!� TEL.NO.
CONSTRUCTION LENDING AGENCY -1
I hereby affirm that there is a construction lending agency for
he it CONTRACTOR C I ,
tperformance of the work for which this permIs issued �J v� C�+^� K td-- t o i
(Sec. 3097, Civ.C.). 5
ADDRESS
Lender's Name s
CITY a
` (— � , TEL.NO.�Y 'L.
Lender's Address t� a
I certify that I have read this application and state that the above LICENSE NO. --h�� p CLASS f'^ 0
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
property for insp c'tioh p pos s. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICA OR AGEN DATE