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HomeMy Public PortalAbout5630 ROSEMEAD BLVD_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0048 DPW 9/89 APPLICATION FOR PERMIT k�,An r G I hereby affirm that I have a certificate of consent to self insure, 76A3fi4C Ior a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING L copy thereof(Sec.3800 Lab.C.) Policy No. Company 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 PDDR UILDING SS �/p3D 77�L�ze� department. (PRINT OR TYPE ONLY) Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS CROSS ST. COMPENSATION INSURANCE � ,O '{y / (This section need not be completed If the work Involved by the MAP BOOK PAGOic.� PARCEL Qom/ permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this mit is Issued, I shall not employ any person in any manners a to BOILER,BTU become subject to the Workers'Compensation Laws. �r COMPRESSOR,BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date �L— Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Cer icate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,you must forthwith comply with such FINAL 1 all, provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY a LICENSED CONTRACTORS DECLARATION FLOOR BTU ;t we VALIDATION= 1 hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (- / ra4 (commencing with Section 7000) of Division 3 of the Business and HEATER: WAL 4.• Professions Code,and my license is in full force and effect. =117? rr_' a 1-1.- Ph ? 9 License Number ..7 5 17 72 LID.Class C Z0 NC'CT a Contractor � �L�7�9 7 bd r,rr• C C EDate mil�w i.,:L o 1l'• El Plan check fee T?, rt r, !'F: I am exempt under Sec. , i _ C B.&P.C.for this reason PERMIT ISSUING FEE$ C46 gf4-� "i'i I AL 651 - 45t Date: - k mak. 651.4r 0 TOTAL FEE Signature PLAN CHECK APPLICANT ':t"�}��t}I: a I.J U OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law NAME for the following reason(Section 7031.5, Business and Professionsa,/��5 Code): ADDRESS _!_ ,5% � ❑ 1, as owner of the property, or my employees with wages �7..:�? i Fri 9:43 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 tion 7044,Business and Professions Code). CITY TEL.NO. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for ONTRACTOR the performance of the work for which this permit Is issued (Sec.3097,Civ.C.). ADDRESS tj� GA Lender's Name CITY TEL.NO. Lender's Address STATE LIC. 1 certify that I have read this application and state that the above LICENSE NO. ��� CLASS -� information is correct. I agree to comply with all County ordinances and State laws relating to building c uction,and hereby authorize representatives of this County to me upon the above-mentioned property f in pection purpose SEE REVERSE FOR EXPLANATORY LANGUAGE 7M 12 SIGNATUAE OF APPUCANT OR AGENTOF DATE F- 7GA364C CE-8981REV.6/78) I , ®5 APPLICATION FOR PERMIT HEATING - VENTILATING !AIR CONDITIONING COUNTY OF LOS ANGELES B3UIWING-AND SAFETY FOR APPLICANT TO FILL IN BUILDING '(PRINT OR TYPE ONLY) ADDRESS 1 d i LOCALITY, �/�/) _ NO. TYPE OF APPLIANCE OR EGIUIPMENT FEE , 'r NEAREST GROSS S ABSORPTION UNIT,BTU J OWNER Gr erV AIR HANDLING UNIT,CFM MAIL ADDRESS BOILER,.BTU CITY TEL.NO. Q��/ CONTRACTOR �f� r COMPRESSOR,BTU ,r / !!! VENTILATION SYSTEM ADDRESS 3 • ~ EVAPORATIVE COOLER CITY TEL.Ng-? FURNACE: FAU GRAVITY STATE LIC. r/ FLOOR BTU LICENSE NO. CLASS L! HEATER: SUSPENDED UNIT_ APPROVALS DATE INSPECTOR'S SIGNATURE WALL ROUGH W� FINAL ` �✓`' ���• INSPECTION RECORD of 1 Plan check fee 25%of above. •, � PERMIT ISSUING FEE$ in TOTAL FEE 0 PLAN CHECK APPLICANT PLAN CHECK VALIDATION NAME ADDRESS i. CITY TEL.NO. IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL ORDINANCES AND LAWS REGULATING HEATING, VENTILATING, AIR coNDITIONING_ PERMIT VALIDATION I HEREBY CERTIFY THAT AM NOT ACTING N VIOLATION OF CHAPTER 9, DIVISION 3. O BUSINES ANAPFESSIONAL CODE OF THE STATE OF CALIFO SIGNATURE O O No � OFPERMITTE N o o ° AID o oO DIST91CT NO. PROCESSED BY N) , cO N —' o OD �1 �7 •o _ •R CO 7 J O O :r. CH 7GA364C ` CE-61BIREV.6/78) APPLICATION FOR PERMIT HEATING - VENTILATING -' AIR CONDITIONING COUNTY OF LOS ANGELES BUILDING AND SAFETY; n. FOR APPLICANT TO FILL INY' JA ILDING (PRINT OR TYPE ONLY) DRES r CALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FE ARESOSSSTABSORPTION UNIT,BTUWNER 10 AIR HANDLING UNIT,CFM IL DRESS q BOILER,BTU CITY �( EL.NO./ � COMPRESSOR,BTU �l/ CONTRACTOR �[ 4721, VENTILATION SYSTEM ADDRESS Q V EVAPORATIVE COOLER CITY ©3TEL. / FURNACE: FAU GR I Y /G LICENSE NSTATE- �/. CLASS FLOOR BTU HEATER: SUSPENDED UNIT_ APPROVALS DATE INSPECTOR'S SIGNATURE WALL ROUGH FINAL I INPIli RECORD pp ,. �f f ?a•n Litt .ry Plan-check fee 25% of above. ' 06 PERMIT ISSUING FEE$ 7 � m, TOTAL FEE PLAN CHECK APPLICANT PLAN CHECK VALIDATION NAME N ADDRESS -7 CITY TEL.NO. / IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND r�r/9 $ n A STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL G ORDINANCES AND LAWS REGULATING- HEATING, VENTILATING, AIR CONDITIONING. , PERMIT VALIDATION• # 0 0 0 o U 1 I HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION OF ` CHAPTER 9, DIVISION 3, OF THE.B SINESS AND PROFESSIONAL CODE 2-o o27,QO OF THE STATE OF CALIF A. - SIGNATURE 2 !,O O I"" D'O o OF PERMITTEE DISTRICT NO. PR OCE D ev 0 -21 6-79 WORKERS'COMPENSATION DECLARATION 76A364C APPLICATION FOR PERMIT I hereby affirm that I have a' certificate of consent to self CE -818 (2-80) insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING a certified copy thereof(Sec. 3800,Lab.C.) Policy No._T.Company ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is filed with the county building inspection department. FOR APPLICANT TO FILL IN BUILDING , # .. , - ADDRESS 4V Date Applicant (PRINT OR TYPE ONLY) I , J } - LOCALITY t1 CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE 0 COMPENSATION INSURANCE NEAREST t;,) (This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. 1L by the permit is for one hundred dollars (5100) or-less.) DISTRICT NO PROCESSED —1 I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM U. - permit is issued, I shall not employ any person in any manner '�"` -"" ' >- so as to become subject to the Workers' Compensation Laws. BOILER, BTU tY - .. ) APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant COMPRESSOR,BTU Im 2 ROUGH O NO'T'ICE TO APPLICANT: If, after maki tg VENTILATION SYSTEM Yhis Certificate of - -- - e- " Exemption, you should become subject to the Workers' FINAL LL! Compensation provisions of the Labor Code, you must.forth- EVAPORATIVE COOLER ` (— with comply with such provisions or this permit shall be VALIDATION deemed revoked. FURNACE: FAU GRAVITY f t. F LICENSED CONTRACTORS DECLARATION FLOOR BTU 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. License Number' t Lie.Class Contractorf� Date r ❑ I am exempt from the licelsing requirements as I am a licensed architect or a registered professional engineer Plan check fee 25%of above. -' acting in my professional capacity (Section 705.1, Bus- .� iness and Professions Code). PERMIT ISSUING FEE $ Lie.or Reg.No. Date _ TOTAL FEE Imo' HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's NAME Y' 1 ' License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): ADDRESS -- t b b • +* ' 1, as owner of the property, will .do the work❑ and the structure is not intended or offered for sale (Section CITY j TEL. NO. „ • • 7044, Business and Professions Code). It ❑ ro ert 4 OWNER 1, as owner of theproperty, r p p y, am exclusively contracting M ° • with licensed contractors to construct the project MAIL (Section 7044, Business and Professions Code). ADDRESS - CONSTRUCTION LENDING AGENCY CITY TEL..N'O. I hereby affirm that there is a construction lendingtagenc> for the performance of the work for which this permit is CONTRACTOR /! i issued (Sec. 3097,Civ.C.). Lender's Name EADDRESSLender's Address " x TEL. NO. I certify that I have read this application and state that the LIC. above information is correct. I agree to comply with all County O. CLASS ordinances and State laws regulating Heating, Ventilating and Air Conditioning, and hereby authorize representatives.of this SEE REVERSE FOR EXPLANATORY LANGUAGE County to, enter upon the above-rytentyoned property for 411•penon purposes.: c.- y Signature of Permittee Date 7GA864c GE-89 8(REV.6/78) ®S APPLICATION FOR PERMIT HEATING - VENTILATING - AIR CONDIT=IONING COUNTY OF LOS ANGELES BUILDING—Aft SAFETY FOR APPLICANT TO FILL IN. BUILDING J (PRINT OR-TYPE ONLY)- ADDRESS LOCALITY; �'y�,' NO. -TYPE OF APPLIANCE OR EQUIPMENT FEE ���`rr NEAREST•: CROSS S ABSORPTION UNIT,BTU r OWNER ' ��. AIR HANDLING UNIT,CFM MAIL ,7� ADDRESS BOILER,BTU CITY , TEL.NO. a `• COMPRESSOR,BTUF___, / T' L�� CONTRACTOR / � r VENTILATION SYSTEM ADDRESS 3 ^• � 1 EVAPORATIVE COOLER CITY TEL.NA FURNACE: FAU wo GRAVITY STATE LIC. /—^ FLOOR BTU LICENSE NO. CLASS,G•- HEATER: SUSPENDED UNIT_ APPROVALS DATE` INSPECTOR'S SIGNATURE WALL ROUGH FINAL• �N INSPECTION RE66RID O Plan check fee 25%of above. _ to PERMIT ISSUING FEE$ TOTAL FEE D PLAN CHECK APPLICANT PLAN CHECK VALIDATION NAME ADDRESS CITY TEL.NO. IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL ORDINANCES AND LAWS REGULATING HEATING, VENTILATING, AIR ;CONDITIONING. PERMIT VALIDATION I HEREBY CERTIFY TH T AM NOT ACTING N VIOLATION OF CHAPTER 9,.DIVISION 3, O BUSINES AND P FESSIONAL CODE OF THE STATE OF CALIFO I . SIGNATURE O O •N �$ kh OF PERMITTE m O DISTRICT NO. PROCESSED BY N ' 0 N - � V VX _ __4D -r__ w7 O O OD 0 C) C) CH