HomeMy Public PortalAbout5729 ROSEMEAD BLVD_Mechanical__ 'WORKER'S COMPENSATION DECLARATION �BBA0384C PW9�� . APPLICATION FOR PERMIT LlVkREEN,
I hereby affirrq that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab C. . "0l
!?certified
Company / �l)a r/ 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 annl°Ess of"�9
depa ent.• (PRINT OR TYPE ONLY)
Data L ApplicantLOCALITY '
NO. TYPE OF APPLIANCE'OR EQUIPMENT FEE
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT BTU
(This section.need not be completed if the work Involved by the MAP BOOK PAGE PARCEL
permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
Is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE ,
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such Q FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU V9', LI ATION
I hereby affirm that I am.licensed under provisions of Chapter 9. HEATER: SUSPENDED UNIT f
(commencing with Section 7000)of Division 3 of the Business and WALL ?,r•:�•1" �
Professions Code,and my license is in full force and effect.
3I � 75ylrjI
License Number .64 L� Lic.ClassI I:fL
L 75 001 C
Contractor DateIL IA�
% iii'.
❑ I am exempt t' Es; ! _ 12 under Sec. Plan Check fee Q D _' 5 G
B.ffP.C.for this reason PERMIT ISSUING FEE$ CHANGE R j I;C
Date: . . TOTAL FEEu
Signature ' L19110—�,00 i fj! �./�j'4
PLAN CHECK APPLICANT V
OWNER-BUILDER DECLARATION , j�.,.,1 :T���C
1 hereby affirm that I am exempt from the Contractor's License Law NAME _5j f e+l�.LI
for the following reason(Section 7031.5, Business and Professions
Code): ADDRESS
1, as owner of the property, or my employees with wages d
as their sole compensation, will do the work and the CITY TEL.NO. P
structure is not intended or offered for sale(Section 7044, a
Business and Professions kj
Code). OWNEReW ¢L OVE 71M
E] 1, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS _024-2-0
tion 7044,Business and Professions Code). 77''
CONSTRUCTION LENDING AGENCY CITY 'Ar TEL.NO. -�3
I hereby affirm that there is a construction lending agency for CONTRACTOR �� V ►
I he performance of the work for which this permit Is Issued (100#
(Sec.3097,Civ.C.).
ADDRESS 5�'
Lender's Name
CITY C /!/1Q�� TEL.NO.
Lender's Address STATE ' / LIC.
I certify that I have read this application and state that the above LICENSE NO. Z Z� CLASS
information is correct. I agree to comply with all County ordinances
and State laws relating to building const'rubtion,and hereby authorize
representatives of this County to enter upon the above-mentioned
propertt or inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
IL
SIGNATURE OF APPLICANT OR AGE IIIATE