Loading...
HomeMy Public PortalAbout5771-5801 ROSEMEAD BLVD_Mechanical__ WORKERS' COMPENSATION DECLARATIONAID-®L I CATION FOR PERMIT I hereby affirm I have a certificate of consent to self insure, or a car : of Workers' Compensation Insurance FI NG - VENTILATING - AIR CONDITIONING or a certified cc. , ..areof (Sec. 3800, Lab. C.) 76A364C l Policy Nodompany_!�r_-r20-0046 DPW 9/88� Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY , Certified copy is filedwith the'c y building inspec- FOR APPLICANT TO FILL IN BUILDING /y r,�j5/ tion department. ADDRESS 6 �lB (PRINT OR TYPE ONLY) / Date Applican LOCALITY P NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FR WORKERS' NEAREST N �e COMPENSATION INSU NCE CROSS ST. "�� (This section need not be completed if the work Involved by ABSORPTION UNI , BTU DISTRICT NO. PROC SSED BY the permit is for one hundred dollars($100)or less.) AIR HANDLING U �j I certify that in the performance of the work for which thisQ O permit is issued, I shall not employ anyperson in any manner so as to become subject to the Workers'Compensation Laws. BC71LE , BTU APPROVALS DATE INSPECrOR'S SIGNATURE r Date Applicant COM R, BTU ROUGH NOTICE TO APPLICANT: If, after making this Certificate of V@I AFION SYSTEM d FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deem- ed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT— ACCT.: (commencing with Section 7000)of Division 3 of the Business WALL. and Professions Code,and my license is in full force and effect. 0� 3A3 7 �5fj, i. 1 License Number Lp�ic. Class TEMS 0 Pooli U O Contractor �Gt / -1c A., [.fX�/te O "3 8� ! S TOTAL SIL 0IR ❑ I am exempt under Sec. _ CHECK .4,-, I Plan check fee CHANGE ,q�• B.BP.C. for this reason Date: PERMIT ISSUING FEE $ RQ a Z OTAL FEE T Signature iptl(1— tLl[),• 11/1 /911 OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License ��• 3825 1 PM 4'56 Low for the following reason (Section 7031.5, Business and NAME Dein r-INGINEERING, Md. JAC121 Ll F Professions Code): ADDRESS VA14 111UYS'"moi $14Q� ❑ I, as owner of the property, or my employees with wages as thele sole compensation,will do the work andCITY 7 the structure is not intended or offered for sale(Section T L. /ovCJJ 7044, Business and Professions Code). OWNS ❑ I, as owner of the property, am exclusively contracting r ' with licensed contractors to construct the project (Sec- AMAIL DDRESS 1 �— �©� tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY TEL.NO::09 � L I hereby affirm that there is a construction lending agency for Poo.the performance of the work for which this permit is issued , CONTRACTOR (Sec. 3097, Civ. C.). ADDRESS � ' '- C.t rte> Lender's Name r rn c'i CITY TEL NO. M. j ;L •,1 „ Lender's Address r 1 N r th I certifythat I have read this application and state that the STATE LIC. PP LICENSE NO. CLASS above 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 rr upo above-�nfioneqdfinspection purposes. 5 SEE REVERSE FOR EXPLANATORY LANGUAGE �C `+. r R r_�T f /(� �Ci Fes: i.�.l 0 Yr L Signat f Applicant or Agent Date �U��/�/••,• ,fin ra } 4�u�t r-"n //��- '� I WORKE i a certifIONicate of consent to 7SA346DPW9/99 A _ICATION FOR PERMIT L� E GREE I hereby affirm that I a certificate of consent to self Insure, 76A394C copy thereof(Sec.3800 Lab CCompensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING Policy No.=Fl S S Company 1 �Jt_ 1 COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. u ertifled copy is hereby furnished. BUILDING Vrl- Certified copy is filed with the county ilding inspection FOR APPLICANT TO FILL IN ADDRESS SS '' 8� department. (PRINT OR TYPE ONLY) Date Applicant I LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST Tel,�` C CERTIFICATE OF EXEM FROM WORKERS' CROSS ST. !//! J COMPENSATI N 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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU ` become subject to the Workers'Compensat n Laws. I d ' COMPRESSOR,BTU Date -_ A licant APPROVALS DATE INSPECTOR'S SIGNATURE PP VENTILATION SYSTEM NOTICE TO APPLICANT: If, aVW fnaking this Certificate of ROUGH Exemption,you should become sul5ject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,you must forthwith comply with such FINAL ��.. provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY �-D VALIDATION LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and WALL Professions Code,and my license is in full force and effect. License Number Lic.Class A17,C- dA Poo. Contract or Date C C El I 4a4gxempt under Sec. Plan check fee Q B.&P.C.for this reason PERMIT ISSUING FEE$ F Date: TOTAL FEE Signature V PLAN CHECK APPLICANT OWNER-BUILDER DECLARATION G I hereby affirm that I am exempt from the Contractor's License Law NAME - for the following reason (Section 7031.5, Business and Professions , 3 Code): ADDRESS n' { 3 I, as owner of the property, or my employees with wages nt, ' 'AT as their sole compensation, will do the work and the CITY TEL.NO. 330/ 19 2. l: structure is not Intended or offered for sale (Section 7044, _ Business and Professions Code). OWNER i j1L I, as owner of the property, am exclusively contracting MAIL TOTAL 192. OID with licensed contractors to construct the project (Sec- ADDRESS tion 7044,Business and Professions Code). f"ECK CONSTRUCTION LENDING AGENCY CITY TEL.NO. I• I hereby affirm that there is a construction lending agency for , �•NANLE .UID the performance of the work for which this permit Is issued ONTRACTOR (Sec.3097,Civ.C.). ADDRESS Lender's Name !, {!(0�130-1011 t ol I-3AM .rC2 1CITY TEL.NO.S:F O 15 9:47. Address STATE LIC. i I certify that I have read this application and state that the above LICENSE NO. r•�T'`7 (J 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 pro f r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGPrWE OF APPLICANT OR AGENT DATE