HomeMy Public PortalAbout5791 ROSEMEAD BLVD_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046DPW g 69 APPLICATION FOR PERMIT LIME GREEN
I hereby affirm that I have a certificate of consent to self insure, 76A364C
or'a certificate of Worker's Compensation Insurance, or a certified HEATING - VENTILATING -AIR CONDITIONING
copy thereof(Sec.3800 Lab. C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished. C
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRE9s
department. (PRINT OR TYPE ONLY)
LOCALITY
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST jM �v„4
CROSS ST G ,!� l
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
ASSESSOR
(This section need not be completed if the work involved by he 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 is ermit
is issued, I shall not employ any person in any m ner o as to BOILER,BTU
become subject to the Workers' Compensa on L C
COMPRESSOR,BTU
_ APPROVALS DATE INSPECTOR'S SIGNATURE
Date�C Cn Applicant VENTILATION SYSTEM
NOTIC TO PLICANT: If, aft 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 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 licenseisin full force and effect.
,aL�License Number �C) Lic.Class C
Contractor �� Date./-Y.) C
❑ I am exempt under Sec. Plan Check fee
B.&P.C.for this reason PERMIT ISSUING FEE $ ZG 7' " C
A ate: TOTAL FEE a
Signature / V
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION L
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
❑ I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS/ 'c— �B
lion 7044, Business and Professions Code).
CITY Z TEL.NO^+�-7 �1, -
CONSTRUCTION LENDING AGENCY n �
I hereby affirm that there is a construction lending agency for CONTRACTOR / 1' AF Poo.the performance of the work for which this permit Is issued r 1
(Sec. 3097, Civ. C.). !�
ADDRESS 4��) S O *h /.
Lender's Name CiJ� ^^ L��7 cC
CITY yJ.32s TEL.NO./ � r
Lender's Address STATE •J LIC. �+
I certify that I have read this application and state that the above LICENSE NO. s% �� CLASS `_--3
information is corre . I agree to comply with all County ordinances
and State laws rel Ing to Ilding construction,and hereby authorize
representative f this unty to enter upon the above-mentioned
proper y t nspe n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SAGNA'TRE OF APPLICANT OR AGENT DATE