HomeMy Public PortalAbout5803-5807 ROSEMEAD BLVD_Mechanical__ WORKERS'COMPENSATION DECLARATION A P P L I CATION •FOR PERMIT
I hereby affirm I have a certificate of consent to self
insure, or a cer a of Workers'Compensation Insurance; H NG - VENTILATING - AIR CONDITIONING
or a certiftecc,_ sreof (Sec. 3800, a . C.) 76A364C
20-0046 DPW 9/88 ` I
Policy No� Company u
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with4FRWORKERS'
building inspect BUILDING
tion department. FOR APPLICANT TO FILL IN ADDRESS ��03-S8O7 90S�1� '6LVO
(PRINT OR TYPE ONLY)
pate / ,G� LOCALITY 'T F_Mi I�LF_ G LTy
—! Applican NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE.OF EXEMPTINEAREST _DP LAS T I-In.S VR.
COMPENSATION INSURANCE CROSS
(This section need not be completed If the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars($100)or less.) !�'
I certify that in the performance pf the work for which this G UNIT, CFM d p
permit is issued, I shall not employ any person in any manner O
so as to become subject to the Workers'Compensation Laws. ' Ell
APPROVALS DATE INSPECTOR'S SIGNATURE
COMPRESSOR, BT .� OUGH
Date Applicant ¢
NOTICE TO APPLICANT: If, after making this Certificate of V(�IJATION SYSTEM I FINAL
*14
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VAI IDATIOW
with comply with such provisions'or this permit shall be deem-
ed revoked. F FAU I�y;s o r
LICENSED CONTRACTORS DECLARATION F% BTU 330 75,1310
1 hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT—
(commencing with Section 7000)of Division 3 of the Business WALL I ITEMS
and Professions Code,and my license is in full force and effect:
�� � G �10 I TOTAL i—P'' m
License Number Lic. Class S'U /�^I pool U
Contracto/ - f��/-Date CHANCE _0*
❑ O
I am exempt under Sec. V
Plan check feloe
B.&P.C. for-this reason PERMIT ISSUING FEE $ 00010-111101 f 1)1q/y�c'�g
Date: U-C I PM 4 e•.Z
Signature TOTAL
'�FF/EE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT f'4►®7 ��
I hereby affirm that I am exempt from the Contractor's License Y,A•
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, 'as owner of the property, or my employees with
ADDRESS 4
wages as their sole compensation,will do the work and CIS, TEL. NO.
the structure is not intended or offered for sale(Section V
7044, Business and Professions Code). OWNER Y ,!
❑ I,as owner of the property, am exclusively contracting '
with licensed contractors to construct the project (Sec- MAIL ®/tom
tion 7044, Business and Professions Code). ADDRESS VV
CONSTRUCTION LENDING AGENCY CITY , TEL. NO.
I hereby affirm that there is a construction lending agency for .
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the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.). ADDRESS g-•, �' 37• I_r
•.r.•i jam, tit *
Lender's Name
CITY TEL. NO. '' % kw, r""
r".•"" ..-t
to7 I.... �iw
Lender's Address STATE LIC. �i—�
F—i
I certify that I have read this application and state that the LICENSE NO. CLASS 8
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction, w
and hereby authorize representatives of this County to enter
BILA iLpINy- "E`t gyp,
elgpnat�q
the a�enned for inspection purposes. SEE REVERSE FOR EXPLAFIATORY L !IGlJi4GE
F....
7 L s
e e
of Applicant or Agent Date