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Home My Public Portal About5809-5819 ROSEMEAD BLVD_Mechanical__ WORKERS' COMPENSATION DECLARATION + APPLICATION FOR P E RM I T I hereby affirm that I have a certificate of consent to self insure, or a certificate.of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C ;20-0046 DPW 9/8.8 Policy No. Company F-1 Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING L, i tion department. (PRINT OR TYPE ONLY) ADDRESS ^�� Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST , \ COMPENSATION INSURANCE CROSS ST. IV (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.) . CFM I certify that in the performance of the work for,which this AIR HANDLING UNIT, �—_ permit is issued, I shall not employ any person in any manner g I R, BTU t so as to become subject to the Workets'Compensation Laws. APPROVALS DATE INSPECTOR'S SIGNATURE JOCDate Applicant MPRE R-BTU ROUGH NOTICE TO APPLICANT: If, after making this Certificate of T IO TTN SYSTEM FINAL �1 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_ 23 (commencing-with Section 7000)of Division 3 of the Business WALL. - and Professions Code,and my license is in full force and effect. S DO Zf ,.fin ACCT. 4 V[,LJ -,-, _ _ License Number Lic. Class `' �I:sO'' 1 j T rM U U Contractor Date• �� ❑ I am exempt under Sec. (I_ITjH s® r Plan check fee • B.&P.C. for this reason PERMIT ISSUING FEE $ Date: CHAPIVC �Z-,`t Signature TOTAL FEE OWNER-BUILDER DECLARATION PLAN CHECK APPLI T t iii,t j _1 � = I hereby affirm that I g r exempt from the Contractor's License NMI HAMLIN STREET SUITE W Law for The following reason (Section 7031.5, Business and NAME sl , `80f4 1 PrI12:01 Professions Code): - ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and CITY vr the structure is not intended or offered for sale(Section 7044, Business and Professions Code). OWNER �`�_0 ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS O CONSTRUCTION LENDING AGENCY CITY TEL I hereby affirm that there is a construction lending agency for the performance"of the work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C.). ADDRESS Lender's Name CITY TEL. NO. Lender's Address 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 upon the above-mentioned property for inspection purposes. S EVERSEE FOR EXPLANATORY LANG AGE Signature of Applicant or Agent Date ��j/G y �/ y @ .....��ddd�� ` WORKER'S COMPENSATION DECLARATION 20.0046 DPW 9/89 AP P L I CA O N FO R P MIT I M E GREEN: 76A364C I hereby affirm 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 ,fopy thereof(Sec.3800 Lab.C.) "d Policy No. Company 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 DD BUILDING 'e — department.department. (PRINT OR TYPE ONLY) . C� Date ApplicantLOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS NEAREST COMPENSATION 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 1 is issued, I shall not employ any person In any manner so as to BOILER,BTU (/ become subject to the Workers'Compe n Laws. o O COMPRESSOR,BTU 0 d v �� 50 A APPROVALS DATE INSPECTOR'S SIGNATURE Date, Lrl/J pplican VENTILATION SYSTEM �� + NOTICE TO APPLICANT: If, ter 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 orthis 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 license is in full force and effect. License Number !` 7 LID.Class `� r ContractorDate y.. C ❑ 1 u- .7 Plan check fee I am exempt under Sec. 1...r, • C B.&P.C.for this reason PERMIT ISSUING FEE$ '(F PC Date: TOTAL FEE 3 LL Signature PLAN CHECK APPLICANTV OWNER-BUILDER DECLARATION `i" e_:"i-: :, I hereby affirm that I am exempt from the Contractor's License Law NAME -,•^t�;_ 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 tion 7044, Business and Professions Code). CITY TEL.NO. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for CONTRACTOR _ Poo.the performance of the work for which this permit Is issued ti (Sec.3097,Civ.C.). ADDRESS yy�r Lender's Name Inc CITY L �� TEL.NO:7 , Lender's Address STATE LIC. I certify that I have read this application and state that the above LICENSE NO: CLASS C— information is correct. I agree to comply with all County ordinances and State laws relating to building construction,and hereby authorize represen tives of this County to enter upon the above-mentioned pro for' s dopurposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 2-- IGNATURILOF AfPPLAMANT OR AGENT v DATE