HomeMy Public PortalAbout5633 ROSEMEAD BLVD_Mechanical__ WORKER'S COMPENSATION DECLARATION 200048 DPW 9/89 ®�P�BCAT°I®I�p ®� 1'ERIIYAI9 �� j,� GREEN
76A364C APPLICATION STI �s ��1�
I hereby affirm that.I have a certificate of consent to self Insure,
or zt ertificat8 of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
Policy Nol S�;Z��'s Company_f��T�T✓-7I) 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 ADDR SS LL
department. f lC (PRINT OR TYPE ONLY)
Applicant( NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY Q ,_ r � �L"
Date��'ZIP
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS
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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. ESSED BY
I certify that in the performance of the work for which this permit
is Issued, I shall not employ any person in any manner so as to BOILER,BTU a6l �• �0�
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant / VENTILATION SYSTEM D
NOTICE TO APPLICANT: If, after making this Certificate of / ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such O FINAL 15 4L Ja 1
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED-UNIT-
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL h
Professions Code,and my license is in full force and effect. AC
CTA
V
License Number-j��y Lic.Class 3343 116.00
L/ { I ITEMS a
ContractoL?�e4 J ��� Date - ^j� ® T+�TpL �.�. a�I� C'
❑ Plan check fee
I am exempt under Sec. CHECK 116.00 �
BAP.C.for this reason PERMIT ISSUING FEE$ (� CHANGE .00 C
TOTAL FEE LI
Signature f in�t r1 �y�t 1 V
O N - IL ER DECLARATION PLAN CHECK APPLICANT _ 0000-00DI PH
1 hereby affirm that I am exempt from the Contractor's License Law NAME e LI:
S- ( W�14-1 ae-- 4 723 I PH I2�37
for the following reason (Section 7031.5, 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 CITYSTEL.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 'L
tion 7044,Business and Professions Code).
CITY TEL.NO.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit Is issued CONTRACTOR--<,17-9—
ONTRACTOR c - S yt
(Sec.3097,Civ.C.). vYT
`
ADDRESS A t- L
Lender's Name
PSTA
� r �� �� TEL.N J
Lender's Address LIC.
I certify that I have read this application and state that the above E NO. J"2 CLASS 6(
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representa' es f this C u y to enter upon the above-mentioned
property r i ction oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
Z— 2 2 _gik
SIWATMW APPLEANT OR AGENT DATE