HomeMy Public PortalAbout5505 ROSEMEAD BLVD_Mechanical__ WORKER$COMPENSATION°ECLA'""°" °'89 APPLICATION FOR PERMIT LIME GREEN
I hereby affirm that I have a certificate of consent to self Insure
or a certificate of Worker a Compensation Insurance or a certified HEATING•VENTILATING•AIR CONDITIONING
copy thereof(Sec 3800 Lab CJ
Policy No� ax-49. -ompany &O"11C'Ntg�- COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING ANDAJAFETY DIV
❑ CeniBed copy is hereby furnished
❑ cadned copy Ie filed with the county budding Inspection FOR APPLICANT TO FILL IN �'LD'NG brr Q�
department --t- /' OR TYPE ONLY)
Datek4l _Appidarn 1 (�1J t.A I.b NO TYPE OF APPLIANCE OR OINPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERSNEAREST
0011APENSATION INSURANCE a�19-11qp O CROSS ST.
(This section need not be completed If the work Involved by they pEBSSOROK pA0 3 pApCELQ/�
permit Is for ole hundred dollars(11100)or less) AIR HANDLING UNITCFM
dancr ro raoctaao er
I tartly that In the pertarmancs of the work for whish this permit
Is Issued 1 shall not employ any person In any manner so as to BOILER BTU
become Subject to the Workers Compensation Lawn 1 Qom' 7-4170,o .p�
�.l COMPRESSOR a IeQ,Coe
AINW.44 rura weecrces eouNe
Date Appa VENTILATION SYSTEMZ-9110
NOTICE TO APPLICANT 11f after making this Certificate ofROUGH 23
Exemption you should become Subject to the Workers Compensation EVAPORATIVE COOLER
provisions of the Labor Code you must forthwith comply with such / F01AL
+
provisions or this permit shelf be deemed revoked FURNACE FAU_GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATIONM] ��',66,W
I hereby affirm that I am licensed under provisions of Chapter a ITER SUSPENDED UNrt_
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code and my%tensa Is In full force and effect
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License Number LLLL71 4 b 3� Lk �
Lilco..� �] 3st5.00
can .oaf kJ CD u�aurnoM Dma11- 3 .3S , � ITEM Qa
❑ 1 am exempt under Sec Plan check f 2
a 0 . TOTALCHECK
11 . 88 (�
B 8P C 10l iib reesmi PERMIT ISSUING FEE S 711.E°o
Date TOTAL FEE O a
Signature co
PLAN CHECK APPLICANT r��t�_,�y� r
OWNER BUILDER DECLARATION 0000-Oval 4/13/73 Z
1 hereby affirm that I am exempt from the Contractors License Law NA&IE 110, 91yX77� 1
for the following reason(Section 7031 S Business and Professions
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 cede (Section 7044
Business and Profesedns Code) OWNER
❑ I as owner of the property am exclusively contracting MAIL
with licensed contractors to construct the project (Sac ADDRESS
don 7044 Business and Professions Code)
CITY TEL NO
CONSTRUCTLENDING AGENCY
ION
I hereby affirm that there le a construction lending agency for BOO.
(Sac
performance of the work for which this permit Is Issued TOR CGAA
(Sac 3097 CN C) ADDRESS S �/ .(�
Leder•Name Q)0Af0 UA),T((
�1K'll AL7M/M CITY W• f TEL M` P7]
Lendara Address STATELrI certify that I have reed this application and state that the above LICENSE NO CLASS
information Is correct I agree to comply with all County ordin°ncee
and State laws rattling to budding construction,and hereby audlorize
representatives of this County to enter upon the abcv mendoned
pr arty for speetiq Pu pones SEE REVERSE FOR EXp6ANATORY LANOUAOE
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uTwE r APP rt los Ao M