HomeMy Public PortalAbout5731 ROSEMEAD BLVD_Mechanical__ WORKER'Shave a certificate
of consent
to - 7BA348DPW9/e9 APPLICATION FOR PERMIT LIME GREEN
78A384C '
I hereby affirm that I have a pertificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(See.3800 Lab.C.)i �,
Po icy No.' Z 43. 3 Colif any N C,)TU�� 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 building inspection FOR APPLICANT OR TYPE TO IN ADDRESS os m �1,3 ej
department. [� ( / �
Date Applicant nkik NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY `� l._G C4 it
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST �`
COMPENSATION INSURANCE CROSS OR M1e/�r
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed If the work Involved by the MAP BOOK PAGEPARCEL
permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
Is issued, I shall not employ any person in any manner so as toBOILER,BTU
become subject to the Workers'Compensation Laws. J_ liL.l/� "v
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNA
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of L ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
License Number Lic.Class
Contractor /JL Data
Plan check fee ACCT.O
❑ I am exempt under Sec. D
B.&P.C.for this reason PERMIT ISSUING FEE$ ''I 3-60J 40.80 F
Date: TOTAL FEE
1 ITEMS u
Signature TOTAL 4113_18+01 u.
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT CASH 40.80
6
1 hereby affirm that I am exempt from the Contractor's License Law NAME &—DDDjj ® r n
for the following reason(Section 7031.5, Business and Professions CHANGE .00
Code): ADDRESS
❑ I, as owner of the property, or my employees with wages U
as their sole compensation, will do the work and the CITY TEL.NO. f!i►Of1_f1f1Ai /�,SfQ�a
structure is not intended or offered for sale (Section 7044, 00 V 0001 i n
Business and Professions Code). OWNER 7599 1 AM 9°n04
❑ 1, 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 agency for CONTRACTOR
the performance of the work for which this permit Is issued �� /()r��,
(Sec.3097,Civ.C.).
6 ADDRESS �9
Lender's Name
CITY v " =r TEL.NO.
Lender's Address STATE C.
I certify that I have read this application and state that the above LICENSE NO. ZWCLASS
information is correct. I agree to comply with all County ordinances
and Stat slat; to building construction,and hereby authorize
repres tatives is County to enter upon the above-mentioned
prop ty for inspe tion purposes. q / SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNAT E OF A OR GENT DATE I G