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Home My Public Portal About5675 ROSEMEAD BLVD_Mechanical__ / WORKEFLK,�OMPENSATION DECLARATION `� ms`s' �— APPLICATION, •ORS e. ERMi� I,.1 .�yvtlffirm that I have a certificate of consent to self i s�fn, x srtific{4te of Workers'compensation Insurance, �; HEATING - VENTILATING `-' AIR CONDITIONING p<a ce tiff d co th of Seco 3 Lab. C.) 76A364C � ��',�!A'��g� CE-918(REV. 10/81) ' Poli rQ'I o. Company /�J/9�7 ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is filed with the cou. ty buil •ng inspec- FOR APPLICANT TO FILL IN BUILDING tion epar ent. (PRINT OR TYPE ONLY) ADDRESS, 10 ArOWL07ew-t— Date h Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCECROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT,BTU DISTRICT NO. PRO ESSED BY the permit is for one hundred dollars(;100)or less.) AIR HANDLING UNIT,CFM �� I certify that in the performance of the work for which this G 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 DATE INSPECT R'S SIGNATURE Date Applicant COMPRESSOR,BTU ROUGH i NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL /' '' Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N F1 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 HEATER: SUSPENDED UNIT '(commencing with Section 7000)of Division 3 of the Business" - WA and Professions Code,and m license is in full force and effect.' Y 0 License Numbe Lic. Class u Contractor Date �m, V ElI am exempt under Sec. - IL U) Plan check fee BAP.C. for this reason*' _ PERMIT ISSUING FEE$ Date: TOTAL FEE J Signature " OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License , Law for the following reason (Section 7031.5, Business and NAME Professions Code): ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and the structure is not Intended or offered for sale(Section CITY TEL. NO. 7044, Business and Professions Code). OWNER El1, as owner of the property,am exclusively contracting with licensed contractors to construct the project (Sec- MAIL ADDRESS 9 5 9 6'2 A tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY L. NO. # 0 0 0 0 0 8 I hereby affirm that there is a construction lending agency for , the performance of the work for which this permit is issued CONTRACTOR /f• I 0 - 51.5,0 (Sec. 3097, Civ. C.). 0 0 a 5 1.5 0 v ADDRESS alt S Lender's Name �i�� ' CITY TEL. NO. 1 1. 1 8=8 6 Lender's Address STATELIC. I certify that I have read this application and state that the LICENSE NO. � CLASS above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and"byautize representatives of this County to enter entioned property for in ecti n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date .,WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT �•rl,hereb�.affirm-that I have a certificate of consent to self 4nsure, ora certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR' CONDITIONING c I d copy fhere�(Sec.�3800, Lab. C.) I 76A3tS4C ,/f ��,, CE-818(REV. 10/81) Vo Icy o S 1 Company �� .V' Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is filed with the county building inspect- FOR APPLICANT.TO FILL IN BUILDING tion department. ADDRESS (PRINT OR TYPE ONLY) , Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed If the work involved by ABSORPTION UNIT,BTU DISTRICT NO. P .ESSE BY the permit is for one hundred dollars($100)or less.) t I certify that in the performance of the work for which this AIR HANDLING UNIT,CFMf� /5 permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. BOILER,BTUAPPROVALS DATE INSPE7OR'S_VI4NATURE COMPRESSOR;BTU ROUGH / Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED-UNIT- '(commencing USPENDED UNIT'(commencing with Section 7000) of Division 3 of the Business WALL and Professions Code,andmylicense is in full force and effect. IL License Number�� Lic. Classes V Contractor 1<7� ZDate 11_ O ❑ I am exempt under Sec. ! i da Plan check fee CL BAP.C. for this reason' PERMIT ISSUING FEE'$ z Date: Signature TOTAL FEE ' • OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License , Law-for the following reason (Section 7031.5; Business and NAME Professions Code): ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and CITY TEL. NO. the structure is not intended or offered for sale(Section 7044, Business and Professions Code). OWNER , ❑ I, as owner of the property,am exclusively con0acting MAIL with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY TEL. NO. 1 hereby affirm that there is a construction lending agency for ' ( o 0 2 Q 5 the performance of the work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C.). o 0 0 2 Q 5 0 5 ADDRESS Lender's Name 1 1,0 IS 8 b � CITY TEL. NO. Lender's Address STATE LIC. I certify that I have read this application and state that the LICENSE NO. CLASS above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby authorizer r sentatives of this County to enter upon t abo lent. p,uperty for inspectio p rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE igna a A^pplicant Agent to v \ 1