HomeMy Public PortalAbout5799 ROSEMEAD BLVD_Mechanical__ WORKER'S COMPENSATION DECLARATION ZO-1104t3DPW 9/99 APPLICATION FOR PERMIT LIME GREEK '"
L 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.)7< 35 ,.(/��.�,
P_ y No./]" Company {'c�f Q 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 ADDRESS S Al, �rV
department. (PRINT OR TYPE ONLY)
Date Z Applicant7 LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION-FROM WORKERS' I NEAREST / , (UhaS
CROSS ST.
COMPENSATION INSURANCE (�0�5
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL
permit Is for one hundreddollars($100)or•less.) ,. AIR HANDLING UNIT CFM
DISTRICT NO. PROCESSED BY
I certify that In the perfor•mance of the work for which this permit
is Issued, I shall not employ,any,person in any manner so as to BOILER,BTU r�p
become subject to the Workers'Compensation Laws. a U
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked'. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provislons of Chapter 9 SUSPENDED UNIT
(commencing with'Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force-and effect.
—3
License Number 473317 Lic.Class {: : oyE
,D a
Contractor d� �dh G✓ iate Z✓L ��Z �� 3307 ` '�'-`- C
❑ Plan check fee !{ C
I am exempt under Sec. a
B.&P.C.for this reasonPERMIT ISSUING FEE$ J!
Date:' �-
TOTAL FEE
Lt
Signature n
PLAN CHECK APPLICANT U,
OWNER-BUILDER DECLARATION
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): , IYi•'r•s n 3
❑ ADDRESS _�? ;•43,
I, as owner of the property, or my employees with wages '•1�•3 43.9413
as their sole compensation, will do the work and the CITY TEL.NO. r-! r j
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). OWNERTOTAL: mi
❑ ..
I, as owner of the property, am exclusively contracting MAIL _, -r,:• ;
with licensed contractors to construct the project (Sec- ADDRESS i•�14�.i,
tion 7044,Business and Professions Code). -
CITY TEL.NO. CHANGECONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for CONTRACTOR r -Yuan
the performance of the work for which this permit Is Issued
(Sec.3097,Civ.C.).
ADDRESS f/L 3 rwZ
Lender's Name -�� ? �a'
CITY�(��, �•Ir TE �s ri!�J� Z II s::. 1 A i �p_6
Lender's Address STATEq� LIC.
I certify that I have read this application and state that the above LICENSE NO. `(� 93 CLASS G
Information is correct. I.agree tD 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 for i9ppectI5 purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
46 I ARPUCANIT OR AGENT ATE -- y