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Home My Public Portal About5751-5757 ROSEMEAD BLVD_Mechanical__ YYUKIICKJ t.lJIVWCIVJ„11UIV VG\.I.PIRP IMAM LIGATION FOR PERMIT I hereby affirm have a certificate of consent to self 1 insure, or a cer. of Workers' Compensation Insurance, w (�� . VENTILUING . AIR CONDITIONING or a certified cop ereof(Sec. 3800, Lab. C.) 76A364C ' r 20.0046 DPW 9/88IM Policy Noy Company S 'e- COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished. . Certified copy is filed with the count building inspec- FOR APPLICANT TO FILL IN BUILDING57757 6� tion department. J (PRINT OR TYPE ONLY) ADDRESS 6 Date _! -Appilican, LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FRO ORKERS' NEAREST I . n �ti A COMPENSATION INSURANCE CROSS ST. 4-i�1S (This section need not be completed if the-work involved by ABSORPTION UNIT, BTU- the [7 ' PROCESSED BY permit is for one hundred dollars($100)or less.) C I certify that in the performance of the work for'which this AIR HANDLING UNIT,CFM � 'D permit is issued, I shall not employ any person in any manner so as to-become subject to the Workers'Compensation Laws. OILER, APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant MPRE R, _ROUGH NOTICE TO APPLICANT: If, after making this Certificate of IILATION SYSTEM �� /��' p( FINAL Exemption, you should become subject to the Workers' " .'Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER �/ LI AT(ON •with comp)y.with such.provisions or this permit shall be deem- 5 ed revoked. FURNACE: • FAU GRAVITY L LICENSED CONTRACTORS DECLARATION FLOOR BTU ` °Z I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED. UNIT_ �, � Q + (commencing with Section 7000)of Division 3 of the Business' WA 3 8. , and Professions Code,and my license is in full force and effect. t ITEMS } License Nujm�byer /� ®Llc. Class p ® TOTAL 78¢ 11V Contractor /'/U ' I:& L11W,Date �_� ^[� �.{"EEK 7-0°� ❑ :•I am exempt under-Sec.. CHANGE ' Plan check fee CC CC B.BP.C. for this reason 2 y PIERART ISSUING FEE $ Date: —0001 111141�� Signature TOTALFEE js� PE� qq 3826 1 Pik 4:56, 'OWNER-BUILDER DECLARATION PLAN CHECK 4PPLl A I hereby affirm that I'am exempt from the Contractor's License -n+ rer tat ""4 Law for the following reason (Section'7031.5,•Business and 'NAME vmf Mm1l1.>w ►STh_6CqF° &LATE 't Professions Code): v °v lwo so" U14wo F-1 1, as owner'of'the property, or my employees with ADDRESS wages as their sole compensation,will do the work and CITY the structure is not intended or offered for sale(Section 7044, Business and Professions Code). OWNER' ❑ I, as owner of the property, am exclusively contracting r " with licensed contractors to construct the project (Sec- MAIL O tion 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY CITY TEL. NO. I hereby affirm that there is a construction lending agency for the performance of the,work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C.). lop ADDRESS C3r,1 ^3 G! }Y�1 Lender's Name C:.. r:ti r CITY TEL. NO. t.,1 1=1 = ire 7.• Lender's Address al %ILIC. _s f~ + ° 1 1 certify that I have read this application and state that the LICENSE NO. CLASS c.:1 ~-1 WW above information is correct. I agree to comply with all County `-' 01 ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter upo th above-mentioned propert or inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGES," `A Signatu Applicant or Agent Date r WORKE MPENSATIONDEConsentto �0048DPW 9/89 A KATION FOR PERMIT LIE GREE I hereby affirm that e a certificate of consent to..If Insure, 78A364C or a certificate of Wor er's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab.C.) Policy NOUMISS Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. Certified copy is hereby furnished. �r FOR APPLICANT TO FILL IN BUILDING department. Is filed with the county building inspection (PRINT OR TYPE ONLY) ADDRESS Date r Applicant LOCALI , NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST CERTIFICATE OF EXEMP ON FROM WORKERS' CROSS ST. COMPENSATION INSURANCE ABSORPTION UNIT,BTU (This section need not be completed if the work Involved by the i ASSESSOR MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or,less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to BOILER,BTU /J become subject to the Workers'Compensation Laws. 1. -O d COMPRESSOR,BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date ApplicantVENTILATION SYSTEM NOTICE TO APPLICANT: If, of aking this Certificate of I ROUGH , Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,you must forthwith comply with suchFINAL Q provisions or this permit shall be deemed revoked. • FURNACE: FAU GRAVITY ' VALIDATION LICENSED CONTRACTORS DECLARATION FLOOR BTU BC7 I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. License Number ( Lic.Class I— a Contractor Date L ❑ I am exempi under Sec. Plan check fee a B.&P.C.for this reason PERMIT ISSUING FEE$ C Ir Date: TOTAL FEE D O G Signature PLAN CHECK APPLICANT U OWNER-BUILDER DECLARATION G_ 1 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 ACC j n F ❑ I, as owner of the property, or my employees with wages _ as their sole compensation, will do the work and the CITY TEL.NO. 31 ?d'L structure is not intended or offered for sale(Section 7044, EM Business and Professions Code). OWNER j L`�� ❑ I, as owner of the property, am exclusively contracting MAIL TO TiPiL -4 a 00 with licensed contractors to construct the project (Sec- ADDRESS tion 7044,Business and Professions Code). � Ev} CITY TEL.NO. _ CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending,agency for the performance of the work for which this permit iissued (Secs CONTRACTOR .3097,Civ.C.). ADDRESSIle?d /JJ r Lender's Name vv i i CITY TEL.NO. �'� r �:'t 1� J. r'!�,i i 9:4- Lender's :4Lender's Address STATE S LIC. I certify that I have read this application and state that the above LICENSE NO. cuss 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 prop ty inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �//��[[//JJ S URE OF APPLICANT OR AGENT