HomeMy Public PortalAbout5821-5827 ROSEMEAD BLVD_Mechanical__ WORKERS"COMPENSATION DECLARATION ®"LICATIOIV FOR PERMIT1 11 .. R
I hereby affirm I have a certificate of consent to self
insure, or a cer : of Workers'Compensation Insurance, H NG - VENTILATING - AIR CONDITIONING
or a certified cr.,, . ."eof (Sec. 3800 Lab. C.) 76A364C
Policy No/ 6 Company Q- >' Lod20-0046 DPW 9/88
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the co ty building inspec- FOR APPLICANT TO FILL IN BUILDING po
tion department. �j (PRINT OR TYPE ONLY) ADDRESS r7rj2� ` �J62� 095emEp-7 bwo
Date 7�-/ — Applican O� LOCALITY TI=M PLC GI
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXI ION NEAREST
COMPENSATION INSURANCE BTU
C OSS ST. LAS TU",N S 179-+
(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(5100)or less.)
I certify that in the performance of the work for which this NIT F O b
permit is issued, I shall not employ any person in any manner G
so as to become subject to the Workers'Compensation Laws. BO APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant ' PRE4f 0 BTU ROUGH ,? q
NOTICE TO APPLICANT: If, after making this Certificate of 'Alk I N SYSTEM FINAL
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. 'E: FAu -
LICENSED CONTRACTORS DECLARATION IMP . BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT—
(commencing
USPENDED UNIT_(commencing with Section 7000)of Division 3 of the Business = WALL f•�
and Professions Code,and my license is in full force and effect. ACCT.°a
License Numbel�i��� Laic. Class ic 9-0 _ , , 3307 90.PM
PM
Lh+^c/�i� G1w3 7-'//—q 1 1 ITEMS awes
Contractod ' ate � z
❑ I am exempt under Sec. , TOTAL 90®00
Plan check fee
B.BP.C. for this reason PERMIT ISSUING FEE t.. CHECK 904;1,
Date: �_ CHANGE °fro
Signature
TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License , 111300— 1301 11/14/91)
1)
Law for the following reason (Section 7031.5, Business and NAME :,'! L, ' 3
Code): u `- PM °5f'
Professions
F-1 1, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY , TEL. NO.
7044, Business and Professions Code). OWNER t�
❑ 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
CONSTRUCTION LENDING AGENCY CITY TEL: NO
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 <1 a%�
Lender's Name
CITY TEL.NO. , , C 3>
Lender's Address 's r" h,. bM
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. CLASS ,
above information is correct. I agree to comply with all County Ll �• �� f�1
ordinances and State laws relating to building construction, B{_IILC� 1)J `tCa 1'-}
and hereby authorize representatives of this County to enter
up he above- entigvled propert or inspectiori purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
`
ignature Applicant or Agent Date
• .ir. F' .-