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Home My Public Portal About5676 ROSEMEAD BLVD_Mechanical__ WORKER'S COMPENSATION PENSATate Of consent to I 2o-DD46DPW 9/s9 APPLICATION FOR PERMIT `I E GREENI hereby affirmthaLt I have a certi}Icate o}consent to self insure, 76A364C or a certificate of Worker's Compensation Insurance, or a certified ; HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab.C.) I u 7 No. /to/41&:R Company �� %�� ' n I COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. Certified copy is hereby furnished. BUILDING ❑ Certified copy is filed with the county wilding i paction FOR APPLICANT TO FILL IN ADDR SS ' r4�7 J dep rtme t. (PRINT OR TYPE ONLY) v f.O / �s�� P�� / Date 3) Applicant ^� LOCALITY /.tv ®� , NO. TYPE OF APPLIANCE OR EQUIPMENT FEE r•� NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' I CROSS ST. COMPENSATION INSURANCE 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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY ` I certify that In the performance of the work for which this permit ^ is issued, I shall not employ any person in any manner so as to BOILER, TU IL become subject to the Workers'Compensation Laws. Ip r v COMPRESSOR,BTU oZ APPROVALS DATE INSPECTOR'S SIGN E Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER FINAL provisions of the Labor Code,.you must forthwith comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION I hereby affirm that 1 am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. License Number Lic.Class 2d C7-_-V ' OL Contractor 4 4�— Date Plan check fee C ❑ I am exempt under Sec. � B.&P.C.for this reason PERMIT ISSUING FEE$ c '2 V Date: TOTAL FEE U0 a Signature C4 OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z I hereby affirm that I am exempt from the Contractor's License Law NAME , 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 CITY TEL.NO. .6'-�`'/f ='o l=' 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 �I// ��,p � ,7 TON 4 I I-II '`y"� °° (--&��f with licensed contractors to construct the project (Sec- ADDRESS �, /�[.7iap/�� 1b tion 7044,Business and Professions Code). �'� �'-'ir r=r:I CITY `j T L_DIO. i i_nF,`• rt'. CONSTRUCTION LENDING AGENCY v I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued CONTRACTOR (Sec.3097,Civ.C.). a! qtr ADDRESS (Jr� es /�✓G 3�I_I,I t : ,n Lender's Name J� / i CITY �(I LW�LC� { ID TEL.NO. (C��D�SS r. Lender's Address `` �'` I certify that I have read this application and state that the above LICENSE NO. (0 2- gj (� LIS —2, i information is correct. I agree to comply with all County ordinances and State laws relating to building construction,and hereby authorize represen Ives of this County to enter upon the above-mentioned pro art or ins tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE off' SIG TU E OF PPLI OR AGENT D E WORKER'S COMPENSATION certificate of consent to 7SA34aDPW9/a9 APPLICATION FOR PERMIT LIME � GREEN. I hereby affirm tha6 I have a certificate of consent to self insure, 78A384C 4 or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab.C.) Poli No. �� Company � Fa-Allo 'COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. Certified copy is hereby furnished. ❑ Certified copy Is filed with the county uilding i pection FOR APPLICANT TO FILL IN BUILDING , C dep rtme t. (PRINT OR TYPE ONLY) ADDRESS V _7Z Date 3! Applicant qWL& NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY 7 a CERTIFICATE OF EXEMPTION FROM WORKERS' I CROSS ST. COMPENSATION INSURANCE ABSORPTION UNIT,BTU (This section need not be completed If the work Involved by the ASSESSOR MAP BOOK PAGE PARCEL permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NOPROCESSED BV I certify that in the performance of the work for which this permit .I Is issued, I shall not employ any person in any manner so as to;I BOILER,BTU become subject to the Workers'Compensation Laws. I�P r COMPRESSOR,BTU oZ ' - APPROVALS DATE INSPECTOR'S 81G E Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL l� provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION II FLOOR sTu VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 1 SUSPENDED—UNIT— (commencing USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. i eLicense Number Lic.Class ALContractor Date 1 , C ' Plan check fee C I am exempt under Sec: �� k e.&P.C.for this reason PERMIT ISSUING FEE$ Date: TOTAL FEE , U11 Signature a OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 2 1 hereby affirm that I am exempt from the Contractor's License Law NAME ► El for the following reason(Section 7031.5, Business and Professions •I A., T Code): ADDRESS ❑ I, as owner of the property, or my employees with wages : —,.�,�� t, as their sole compensation, will do the work and the CITY TEL.NO. 3301 structure is not intended or offered for sale(Section 7044, -plc F1 Business and Professions Code). OWNER ®/ei® G z I I, as owner of the property,-am exclusively contracting MAIL / �,� TOTAL ITA{ 4°9• - 00 with licensed contractors to construct the project (Sec- ADDRESSE� , tion 7044,Business and Professions Code). CHECK 43.1'11,Jf, CONSTRUCTION LENDING AGENCY , CITY T I..NO. r_tI I hereby affirm that there is a construction lending agency for CONTRACTOR , the performance of the work for which this permit s issued (Sec.3097,Civ.C.). ADDRESS /�. 9^yf��_ �n 7;� 1 Lender's Name /�// Iwo �/ /� / IJIJ 11J f.l)tJ 1t �.��_r L''1191 CITY l� w o ID TEL.NO. �fCS�V��7 3��j'=i Z 1 Ark til-.1 Lender's Address `` �+ I certify that I have read this application and state that the above IL CENSE NO. b LIC. — `— information Is correct. I agree to comply with all County ordinances and State laws relating to building construction,and hereby authorize represen Tues of this County to enter upon the above-mentioned pro a or ins tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE y SIGNATURE OF APPLIGANT OR AGENT D E