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Home My Public Portal About5819 ROSEMEAD BLVD_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 APPLICATION FOR PERMITLIME GREEN: 76A364C I heieby 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 copy thereof Sec.3800 Lab.C.) Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. D �9.- Certif' d copy Is hereby furnished. ❑ Certified copy is filed with the count buildinginspection FOR APPLICANT TO FILL IN BUILDING 6 r�t. y p (PRINT OR TYPE ONLY) ADDRESS 77VVSS 771 < Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS ST: 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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU become subject to the Workers'Compensa'on Laws. COMPRESSOR,BTU APPROVALS- DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this ertiflcate ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER fl p provisions of the Labor Code, you must forthwith comply with such / FINAL /©_r L'• provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR _BT u VALIDATION' . I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNITAqrr _c (commencing with Section 7000) of Division 3 of the Business and HEATER: WALL ACCI .T Professions Code,and my license is in full force and effect. 13.,_. 292.50 License Number 7. Lic.Class _ A�.`CT•T a Vi •. Contract o Date . `307 p�acc C EJ Plan check fee V . I am exempt under Sec. ITEMS i�� lI� B.&P.C.for this reason PERMIT ISSUING FEE$ _ Date: �� TOTAL ,_�� 05 c TOTAL FEE LL CHECK Signature c o V. OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT F 1 Is! Z CHANGE O•- 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): e): ADDRESSf2�1 O ' I, as owner of the property, or my employees with wages �V�Q— IJQZ v/'"�f2 9 as their sole compensation, will do the work and the CITY TEL.NO. 9 522 1 AM u:Cj structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER ❑ I, as owner of the properly, 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 the performance of the work for which this permit Is issued CONTRACTOR (Sec.3097,Civ.C.). F ADDRESS </ !/ Lender's Name STA—TE Y TEL.NO. Lender's Address LIC. I certify that I have read this application and state that the above ENSE NO. �l CLASS — information is correct. I agree to comply with all County ordinances and State laws relating to building construction,and hereby authorize represent es of this Count to ter upon the above-mentioned pr ot f r inspecti u or�� SEE REVERSE FOR EXPLANATORY LANGUAGE SIGMA F AppLICANT RAG' T DATE WORKER'S COMPENSATION 76A366DPWg/69 APPLICATION FOR PERMIT LIME 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 `IIuII copy thereof(Sec.3800 Lab.C.) y Policy No. Company ` o"P�" COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Certified copy is hereby furnished. ❑ Certified copy is filed with the county buildinginspection FOR APPLICANT TO FILL IN BUILDING department ( PRINT OR TYPE ONLY) ADDRESS (% Date -9 7--Applicant / /, d�/ ~ LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS ST. COMPENSATION INSURANCE ABSORPTION UNIT,BTU (This section need not be completed if the work involved by the MAPESSOR BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU (� � become subject to the Workers'Compensation Laws. �e COMPRESSOR,BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLERQ provisions of the Labor Code, you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVI JY VALIDATION LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000) of Division 3 of the Business and HEATER: WALL r Professions Code,and my license is in full force and effect. 55&7 License Number Lic.Class .L �ie�l 7�•Pi.. J ' ." i�!`-t_. ° Contractor /l��g2/d o Date , " Plan check fee ❑ I am exempt under Sec. +'' v � 13 B.&P.C.for this reason PERMIT ISSUING FEE$ Date: TOTAL FEE _ U .c Signature � __ �'�'r OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License Law NAME I-I a ut �• -tY �-�- for the following reason (Section 7031.6, Business and Professions a - _s-_s Code): ADDRESS �)jl^S_I;k -7t°cc ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the CITY TEL.NO. r%! 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 7 with licensed contractors to construct the project (Sec- ADDRESS I`I -°-` ' tion 7044, Business and Professions Code). :t i 1 a %�19CITY TEL.NO. --• CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for ,,,CONTRACTOR the performance of the work for which this permit Is issued- p (Sec.3097,Civ.C.). ADDRESS /J Lender's Name L �y CITY TEL.NO. Lender's Address STATEj LIC. �JJ T I certify that I have read this application and state that the above LICENSE NO. 73 6 !'7 CLASS information is correct. I agree to comply with all County ordinances and State laws elating to building construction,and hereby authorize represen ati of this Cou ty to enter upon the above-mentioned grope f Inspection p es. 9 SEE REVERSE FOR EXPLANATORY LANGUAGE SIGVTURE OF APPLICANT On AGENT DATE