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Home My Public Portal About5721-5747 ROSEMEAD BLVD_Mechanical__ WORKERS'-COMPENSATION DECLARATION A n"LICA►TIO.N FOR PERMIT 1 I -hereby affirm have a certificate of consent to self � V � insure, or a co of Workers' Compensation Insurance, H0 IG - VENTILATING • AIR CONDITIONING � or a certified ca reof (Sec. 3800, Lab. C.) 76A364C Polis No. S7 y'•P- F(,f 20-0046 DPW 9/88 Policy Company Q- Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ' ❑ Certified copy is filed with the coun y building inspec- 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 FRO ORKERS' NEAREST COMPENSATION INSU CE CROSS ST. (This section need not be completed If the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY the permit is for one hundred dollars($100) or less.) I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM_ permit is issued, I shall not employ any person in any manner le- so as to become subject to the Workers'Compensation Laws. BOILER, OU APPROVALS DATE ItRECTORS SIGNATURE cc SSO TLJ� ROUGH Date Applicant , NOTICE TO APPLICANT: If, after making this Certificate of A ION SYSTEM �L `J FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit'shall be deem- ed revoked. NACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION ' FL R BTU I hereby affirm that I am licensed under provisions of Chapter H TER: SUSPENDED—UNIT _ (commencing with Section 7000)of Division 3 of the Busine s WALL ACC I•a and Professions Code,and my license is in full force and effec License Number��J Lic. Class G�Q 0 LS ```� ? t T �,t- LI4d 5 Contractor+/ ire 14: �'+-/ate ` , I t TIE tv V -30 _g3 HE. X04�� ❑ • I am exempt under Sec. CHECK t— Plan check fee - r w• B.&P.C. for this reason PERMIT ISSUING FEE $ CHANE °�11 Date: _ TOTAL FEE • Signature ,�.t, M .;,� 13000-0001 11!14 90 OWNER-BUILDER DECLARATION PLAN CHECK APPLI ®VA �(`a�(oaC:.� .%+•� I:'•; I hereby affirm that I am exempt from the Contractor's License ew 3824 j PM 455Law for the following reason (Section 7031.5, Business and NAME fif�.c�i Professions Code): ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and Im the structure is not intended or offered for sale(Section CITY .�� 7044, Business and Professions Code). OWNS ❑ I, as owner of the property, am exclusively contracting g� ' with licensed contractors to construct the project (Sec- AMAIL DDRESS tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY TEL. NO. 37 .- Ihereby affirm that there is a construction lending agency for LF)En the performance of the work for which this permit is issued CONTRACTOR (Sec..3097, Civ. C.). 01111. ADDRESS , i r, -•-I Gtit x., 4•c� Lender's Name Cn I`s r. CITYTEL. NO. Lender's Address I certify that I have read this application and state that the STATE LIC. i .iLICENSE NO. CLASS C=' above information is correct. I agree to comply with all County ��- ordinances and State laws relating to building construction, a • and hereby authorize representatives of this County to enter upo t e above- entioned prop ty for inspec/tionppurposes. SEE REVERSE FOR EXPLANATORY LANGUAGE -. p' —.07"�/ ` ! / ,y/r 'X w Fa R �i Signature Applicant or Agent Date �t✓/G�l -`� • e i L9 WORKEI MPENSATION DECLARATION 20-0048 DPW 9/89 _. I hereby affirm that , a certificate of consent to self insure, 78A384C A -(CATION FOR PERMIT LI E GREE or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800�La*b-.C.) "0 Policy No.. V 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 ADDRESS Z department. (PRINT OR TYPE ONLY) Dateef" Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY CERTIFICATE OF EXEMPTI FROM WORKERS' NEAREST N 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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU be-Dome subject to the Workers'Compensation Laws. O COMPRESSOR,BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL Z_ provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY- LICENSED RAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU- 80 VAO_IDATION 1 hereby affirm that I am licensed under provisions of Chapter9 HEATER: SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and WALL Professions Code,and my license is in full force and effect. License Number [ G LID.Class _ Contracto Date r ❑ Plan check fee I am exempt under Sec. C 'B.&P.C.for this reason PERMIT ISSUING FEE$ Date: TOTAL FEE p 9 Signature (J, PLAN CHECK APPLICANT OWNER-BUILDER DECLARATION 6 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 -" El 1, as owner of the property, or my employees with wages WA.-I °g as their sole compensation, will do the work and the CITY TEL.NO. _7'.G7 structure is not intended or offered for sale(Section 7044, _ _ Business and Professions Code). OWNER i i l 1=M,: ❑ I, as owner of the property, am exclusively contracting AIL �--r,t .ate.. 1 with licensed contractors to construct the project (Sec- ADDRESS I!}'S^�BI^ r� a tion 7044, Business and Professions Code). �;�;E;"K 16`8°C(I, CONSTRUCTION LENDING AGENCY CITY TEL.NO. e 1 hereby affirm that there is a construction lending agency for ® �•i'AINGG .131.;the performance of the work for which this permit Is issued CONTRACTOR (Sec.3097,Civ.C.). d ADDRESS I_i :ILI`LIItiI 1 7 tli 7 3 1 Lender's Name CITY TEL.NO. yZ3 FF !!ny I certify haul have read this application and state that the above ss LICENSE NO. LIC. /s /if'� CLASS information Is correct. I agree to comply with all County ordinances and State laws relating to building construction,and hereby authorize representatives of this County to enter upon the above-mentioned propsnspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNIKKE OF APPLICANT OR AGENT DATE