HomeMy Public PortalAbout5610-5618 1/2 ROSEMEAD BLVD_Mechanical__ WORKERS COMPENSATION DECLARATION " f
I hereby affirm that I hove o c rtib ficaof consent to sxelf
insure Cr a certificate of Workeri Compensation Insurance HEATING - VENTILATING - AIR CONDITIONING
or a certified cgpy lhereof (Sec 3800, Lob C ) 76A364C
A CE BIB(REV 10/81)
Poli Company
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the ount) building inspec- FOR APPLICANT TO FILL IN BUILDING O
I d
i nepartment (PRINT OR TYPE ONLY) ADDRESS
Date j 7182 Applicant LOCALITY 46
NO TYPE OF APPLIANCE OR EQUIPMENT FEE Nr�
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST
(This stolon need not be completed If the work Involved by ABSORPTION UNIT BTU DISTRICT NO PROCESSED BY
the permit Is for one hundred dollen($100)or less)
I certify that in the performance of the work for which this AIR HANDLING UNIT CFM 1 V
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permit is issued I shall not employ any person in any manner BOILER BTU
so as to become subject to the Workers Compensation Lows APPROVALS DAIT IN S SwNTUBE
Date A.pphcont COMPRESSOR BTU ROUGH
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM 9 12dfl FINAL
Exemption, you should become subject to the Workers
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VALIDATION
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 HFATER SUSPENDED—UNIT—
(commencing
USPENDED UNIT_(commencing with Section 7000) of Division 3 of the Business WAIL IG
and Professions Code,and my Incense is in full force
'�anndeffect
License Num/b�er AQ71 Pc✓ LIc Classceefes DrV
IN
Contractor✓ %Auatw Date O
❑ I am exempt under Sec
Plan check fee
B 8P C for this reason w
Date
PERMIT ISSUING FEE $ 39842 Z
A
Signature TOTAL FEE #4 s e e - 8
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
1 hereby affirm that I am exempt from the Contractor s License , I - I 9 U 5 0
Law for the following reason (Section 7031 5 Business and NAME
Professions Code) • e 1 9 p 5 Q
❑ I, as owner of the property or my employees with ADDRESS
wages as their sale compensation will do the work and 0 & 09-88
the structure Is not Intended or offered for sale(Section CITY TEL NO
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
CONSTRUCTION LENDING AGENCY CITY TEL NO
1 hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is Issued CONTRACTOR �'�,(' S
(Sec 3097 Civ C ) - -
I L
ADDRESS W �J - . -
Lender a Name
CITUbjqyjb�7111TEL NO57
4-J �3
Lender s Address hiAlt LIC
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I certify that I have read this application and state that the LICENSE NO 497 2 CLASS G^W -
above Information is correct I agree to comply with all Couny
9ZElaws relating to building construction
esentatives of this Couny to enteroned property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE _
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Signoture of Applicant or Agent Dote