HomeMy Public PortalAbout5701-5711 ROSEMEAD BLVD_Mechanical__ WORKER'S COMPENSATION DECLARATION 6DPW 8/89 f� APPLICATION FOR PERMIT LIME GREEN
76A36
I hereby affirm that I have a certificate of 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.)
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 BUILDING
department. (PRINT OR TYPE ONLY) ADDRESS (f
LOCALITY,. 5 r
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
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 BOIL ,BTU (/
become subject to the Workers'Compens n Laws. L _ 1 p p
i C ESSOU Z, �S ) '
Date�� l� / L" A IICa APPROVALS DATE INSPECTOR'S SIGNATURE
PP VENTILATION SYSTEM
NOTICE TO APPLICANT: If, ter making this Certificate of ROUGH
Exemption, you should became 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 A' 1D ION
LICENSED CONTRACTORS DECLARATION FLOOR BTU 6'
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 and WALL
Professions Code, and my license is in full force and effect. /
�. // I.t1C_r_�
License Number 7�� Lic.Class
Contrac�+ ;1�'SJ Date�_/i — �- /',� v C
ElI am exempt under Sec. Plan Check fee / a
B.&P.C.for this reason PERMIT ISSUING FEE $ Z / ,L� C
Date: TOTAL FEE / (j y(( LL
Signature a
PLAN CHECK APPLICANT 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 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.
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).
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit Is issued
(Sec. 3097,Civ. C.). --7
ADDRESS 7! L ✓ �L
Lender's Name
C 7�, �, C TEL.NO•.��S(�_. '
Lender's AddressSTATE
I 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 construction,and hereby authorize
represen ves of this County to enter upon the above-mentioned
;Zlo/,n e i oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
IGNATURE OF APPLICANT OR AGENT DATE