HomeMy Public PortalAbout5725 ROSEMEAD BLVD_Mechanical__ WORKER'S COMPENSATION DECLARATION ►364DPW 9/89 APPLICATION FOR PERMIT LIME GREEN
I hereby affirm that I have a certificate of cQohseht to self Insure,
or a certificate ofMorker's Compensation Insurance, or a rtified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
PoI' y No. Company 7�/ u'�
COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ rtified copy Is filed with the county building Inspection FOR APPLICANT TO FILL IN BUILDING
ADDRESS S 7a� v L�4Q
rtment. (PRINT OR TYPE ONLY)
Date 7 / Applicx:: ®E� NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
Cpa
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST 1-14
CROSS ST.OR (/J✓AS
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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
Is Issued, I shall not employ any person in any manner so as to BOILER,BTU � �i
become subject to the Workers'Compensation Laws. e-1'tq 0 94v��,,
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH _
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION. ..:_
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL :�7
Professions Code,and my license is In full force and effect. ';'r`11
i iTENs
License Number nq Lic.Class C
�x�s�N 3n , TOTAL 50.70
Contract"'O� e./w, ate /� �+ t:HEK(. ~`(-e c{,C
❑ I am exempt under Sec. Plan Check fee CHANGE ` a
Q
B.BP.C.for this reason PERMIT ISSUING FEE$ C
Date: TOTAL FEE 0l.'iIJIL!—I1111}� � ="' (F
Signature 468 1 AMI i
PLAN CHECK APPLICANT (%
OWNER-BUILDER DECLARATION 2
1 hereby affirm that I am exempt from the Contractor's License Law NAME�� � 1111110-
for
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 theCITY N�Q��' 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).
CITY TEL.NO.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction lending a�ency for CONTRACTOR ,
the performance of the work for which this permit s Issued
(Sec.3097,Civ.C.). ' ! ,
ADDRESS V AL L de
Lender's Name
CITY �i TEL.NO.3J 0_/,'ry �p
Lender's Address
I certify that I have read this application and state that the above LICENSE NO. �l �� CLCASS
information is correc I agree to comply with all County ordinances
and State laws g to building construction d hereby authorize
representativ this to por e a ve-mentioned
property SID ction p os / / SEE REVERSE FOR EXPLANATORY LANGUAGE
SIG? URE OF APPLECANT O Ag DATE