HomeMy Public PortalAbout5745 ROSEMEAD BLVD_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-OW JPW'9189 APPLICATION
®�Y I�R T�®IY ®fl ���INA I� LIME GREEN.
I hereby affirm that I have a certificate of consent to self Insure, 78A384CI /°fir 6 A 1
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.) ss
Policy No. Company Sf� fJ/�noC. COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ ertified copy is hereby furnished. 1
Certified copy Is filed with the county building Inspection FOR APPLICANT TO FILL IN ADDRESS.j�y� �f�jfn � Iti7��CiCr
department. (PRINT OR TYPE ONLY)
Date Applicant LOCALITY !C�
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAR
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSSSST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work Involved by the ASSESSOR
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM MAP BOOK PAGE PARCEL
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 FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION IFLOOR BTU ALB ATION'
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 licensee is in-full force and effect. I� s h<ctld-s
License Number 76a3�� LID.Class ® >
Contractor 60 r"�+~ `�"• Data 7+16 r�� :t:-i :a C
Plan clieck fee �_ {? ' "I.`- ` C
❑ I am exempt under Sec. - -
BAP.C.for this reason PERMIT ISSUING FEE$ 7r
net TOTAL FEE l' L
Signet u9ag '�-ice`•1 _,I.a C
PLAN CHECK APPLICANT C
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 wagesi• `wi
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale(Section 7044, I `i`:"�� ' l'•'I
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 agency for CONTRACTOR
the performance of the work for which this permit Is issued
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name
CITY TEL.NO.
Lender's Address STATE LIC.
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
representatives of this County to enter upon the above-mentioned
Mor Inspection 31;,, SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT DATE .