HomeMy Public PortalAbout5624-5626 ROSEMEAD BLVD_Mechanical__ WORKERS'COMPENSATION DECLARATION I CEA3B64BC(Z Bo) fA Ick p �� A fry p FOR
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I hereby affirm that I have a' certificate of consent to self A lf� L A i�I I!— Ifs E Ifs 11 711
,Ansure,or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
/ a certified copy thereof(Sec.3800,Lab.C.)
Policy Compan
El Certified copy is hereby furnished.y COUNTY OF LOS ANGELES `/ l I BUILDING AND SAFETY
I
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
department.
Date Applicant (PRINT OR TYPE ONLY) ADDRESS
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE I NEAREST ` _/ }
(This section need not be completed if the work involved ABSORPTION UNIT,BTU CROSS ST. /� O
by the permit is for one hundred dollars ($100) Or less.) DISTRICT NO. ,,// PROCESSED Y C.)
I certify that in the performance of the work for which this , AIR HANDLING UNIT,CFM O p W
permit is issued, I shall not employ any person in any manner j d O
so as to become subject to the Workers'Compensation Laws. BOILER,BTU 13
APPROVALS DATE ,, INSPECTOR'S SIGNATURE
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k.ate Applicant jI COMPRESSOR,BTU 4 10 ROUGH ✓� Z
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NOTICE TO APPLICANT: If, after making this Certificate of I VENTILATION SYSTEM
Exemption, you should become subject to the Workers' FINAL.
Compensation provisions. of the Labor Code,;you must forth- EVAPORATIVE COOLER
with comply with such provisions or this permit shall be I VALIDATION
deemed revoked.
LICENSED CONTRACTORS DECLARATION i FLOOR: FAU BT VITY
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code,and my license is in full force and
effect. 2.9 LicG--ZO
License Numbe .Class
Contractor 1 *-J.Z- Date -T—ZZ j
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional 'engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus1.
-
iness and Professions Code). PERMIT ISSUING FEE$ ® et
Lic.or Reg.No. Date I TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from-the Contractor's.. NAME M M 2 Q Q,9 A
License Law for the following reason (Section 7031:5;'Busi-
ness and Professions Code): ADDRESSw L ##0 0 0 0 o
M I, as owner of the property, will do the work and the CITYMO TEL.NO. ?
structure is not intended or offered for sale (Section 090 A � '�i7 2o o 3 G Fj Q
7044,Business and Professions Code).
I, as owner of the property, am exclusively contracting OWNER M O ro,o.o 3 0,'5 0 25
with licensed contractors to construct the project MAIL J�w s Ly 0 5, 1 61-83
(Section 7044,Business and Professions Code). ADDRESS vJ� &M31 AJ
CITY TEL.NO. �r ..
CONSTRUCTION LENDING AGENCY l$ ZA 7 1177
I hereby affirm that there is a construction lending agency CONTRACT R
for the performance of the work for which this permit is
L
4. AjR-
issued 3097,Civ.C.). r
Lender s Name ADDRESS Zc 1
Lender's Address CITY Q N�Q TEL.Nt3r9_,&
I certify that I have read this application and state that the STATEs LIC.
above information is correct.I agree to comply with all County LICENSE NO. �7 - CLASS
ordinances and State laws regulating Heating,Ventilating and I
Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
Count to enter upon the above nt'oned properly for
i action rpose �_
Signature of Perm tee Data