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Home My Public Portal About5749 ROSEMEAD BLVD_Mechanical__ ION WORKE MPENSATate of consent to 78A33664C DPW 9/89 A _ICATION FOR PERMIT LI E GREE I hereby affirm that i 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.) Policy No.=?IS S Company A 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 BUILDING department. (PRINT OR TYPE ONLY) ADDRESS Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPAVROM WORKERS' NEAREST CROSS 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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO PROCESSED BY I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in any manner so as to BOILER,BTU become subject to the Workers'Compensation Laws , COMPRESSOR,BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL 0. provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT 100 (commencing with Section 7000)of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. y� License Number 51 Z515 S Lic.Class. ^ a a Contractor Date C F1I am exempt under Sec. Plan Check fee O B.&P.C.for this reason PERMIT ISSUING FEE$ F Date: TOTAL FEE *2.pp L Signature PLAN CHECK APPLICANT OWNER-BUILDER DECLARATION a I hereby affirm that I am exempt from the Contractor's License Law NAME for the following reason (Section 7031.5, Business and Professions Coe): ADDRESS I, as owner of the property, or my employees with wages z�.'_i °v as their sole compensation, will do the work and the CITY TEL.NO. L;V_If` structure is not intended or offered for sale (Section 7044, _ Business and Professions Code). OWNER E ❑ I, as owner of the property, am exclusively contracting MAIL72 00with licensed contractors to construct the project (Sec- ADDRESS '117-NAL tion 7044,Business and Professions Code). CITY TEL.NO. 1- `'li i°, 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 C (Sec.3097,Civ.C.). ADDRESS { Lender's Name r 140 CITY TEL.NO. i .2 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 pr inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE d / SI RE OF APPLICANT OR AGENT ATE WOthat MPENSATION DECLARATION 7OA346DPW9189 Al .ICAT1ON FOR '�IT IME GREE Jogn I hereby affirm that a certificate of consent to self Insure, 78A364C or a certificate of Worner b Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab.C.) Policy No. /moo 9/s sr�f� F Company ter"' COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. Certified copy Is hereby furnished. 91-1-191 FOR APPLICANT TO FILL IN BUILDING Certified copy is tiled with the county building inspection ADDRESS (PRINT OR TYPE ONLY) 7 department. n LOCALITY Date 7 'q Applicant 0� NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST CERTIFICATE COMPENSATONEXEMPTION NSURANCEWORKERS' ` /�Ob �� O CROSS ST. (This section need not be completed If the work involved by the ASSESSOR n MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) 3 AIR HANDLING UNIT,CFM-= O O v( O DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit Is issued, I shall not employ any person in any manner so a 'to B LER,BTU become subject to the Workers'Compensation Laws. CO PRESSOR.BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant _VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of 00 ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY VALIDATI N LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. o,O 0(> Q7C.0 0'0 License Number / � Lic.Class C ' 3 Oa<) 127-CL 0.0 atIA Contractor A'r C-,&,�` ate 7- 24 ` ❑ 1 am exempt under Sec. 4/_gVIW Ple el w* 04 I-e S B.&P.C.for this reason PERMIT ISSUING FEE$ Date: TOTAL FEE 490 Signature PLAN CHECK APPLICANT 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 O `r �^•"' Coe): ADDRESS C� / Q �f �-�i.lo'•.,b t'^1 � rtii•lri a4 1, as owner of the property, or my employees with wages as their sole compensation, will do the work and the CITY TEL.NO. 7/IL__roll?448 z._•.)j� `sr r Business and Professions Code). �� vUIJ structure is not intended or.offered for sale(Section 7044, -- y�- OWNER f /'�Ob� + '-t L'`• ❑ I, as owner of the property, am exclusively contracting MAIL ' / j O I AL 477 . 00 with licensed contractors to construct the project (Sec- ADDRESS S CLM-c._ _ tion 7044,Business and Professions Code). CITY TEL.NO. CHECK 477,,1:' CONSTRUCTION LENDING AGENCY a I hereby affirm that there is a construction lending agency for �^ ® t•HANiGE .00 the performonce of the work for which this permit Is issued CONTRACTOR /D C r (Sec.3097,Civ.C.). G ADDRESS �Fj 3:13-0-33-Ji ?/it/'t`i Lender's Name CITY G„ TEL.NO.',Z,13 �!�� Lender's Address STATE LIC. Art U �� 1 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 property fpr inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE APPLICANT OR AGENT DATE