HomeMy Public PortalAbout5805 ROSEMEAD BLVD_Mechanical__ WORKER'S COMPENSATION DECLARATION 7SAA864CPW 9/89 APPLICATION FOR PERMIT LIAAE GREEN
I hereby s�ffirm that I have a certificate of consent to self insure,
or a certificate•of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.-3800 Lab.C.) "d
Pollcy No.z�7� -Company. COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑
Certified copy is hereby furnished.
0 Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
department. (PRINT OR TYPE ONLY) ADDRESS d Ave-
Date —Applicant-—Applicant���� G LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS
COMPENSATION INSURANCE
ABSORPTION UNIT,BTU- e7 ASSESSOR
(This section need not be completed if the work Involved by the I 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 06
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INS P TOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGHZ3,O��j
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 VA ATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
HEATER:
(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 4 37b1 Lic.Class 23
>i�7 �Cr�l Date L�—z,S-- 6� ACCT o 4 C
Contractor 3303 248.70 C
❑ Plan check feeIx
I am exempt under Sec. 1ITEMS C
BAP.C.for this reason PERMIT ISSUING FEE 070 — H
Date: TOTAL 24-41-31o 7113 u
7jor' CHECK 248.70 a
Signature � V.
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT �� CHANGE a 00 �
1 hereby affirm that 1 am exempt from the Contractor's License Law NAME ,
for the following reason (Section 7031.5, Business and Professions 8
Code): ADDRESS —
❑ I, as owner of the property, or my employees with wages Wl`L('.9001 4/25/96
as their sole compensation, will do the work and the CITY TEL.NO. 1
structure is not Intended or offered for sale(Section 7044,
Business and Professions Code). OWNER1; 1 ITEMS
❑ I, as owner of the property, am exclusively contracting MAIL TOTAL �.A a o, �
with licensed contractors to construct the project (Sec- ADDRESS 7
tion 7044,Business and Professions Code). CHECK 157 a 30
CONSTRUCTION LENDING AGENCY CITY TEL.NO. I
I hereby affirm that there is a construction lending agency for LADDRESS
OR , CHANGE .00
the performance of the work for which this permit Is issued Ane�
(Sec.3097,Civ.C.).
Lender's Name 0000-0001 5/ 9/96
TELN 6326 1 AM1005b
Lender's Address LIC. !
I certify that I have read this application and state that the above LICENSE NO. 6376,17CLASS l
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 erty for in ction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
l-
ATUREF APPLICANT OR AGENT LATE