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Home My Public Portal About6004 ROSEMEAD BLVD_Mechanical__ %%ORKERS'C(j�IPI'NSATION DI'sCi_ARATION I CEA 818 C(2 80) A P P UC AT Q O N FOR P E R WII f� I hereby affirm that I have a' certificate of consent to %elf imure, or a certificat:of Workers'Compensation Insurance,or HEATING-VENT IL.ATI NG-Alla CONDITIONING U certified copy thereof(Sec.3800,Lab.C.) Policy No. Company Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy I,filed with the county building inspection department. FOR APPLICANT TO FILL INBUIL DING; L' Dste �ppllcunt I (PRINT OR TYPE ONLY) - ADDRESS LOCALITY - CFRTIFIC'AI I OI'EXEMPTION FROM WORKERS' � NO. TYPE OF APPLIANCE OR EQUIPMENT FEE _ __ ____ _ COMPENSATION INSURANLIE NEARESTd (This section need not be completed if the work involved I ABSORPTION UNIT,BTU____ CROSS ST. O by the p2tmit is for one hundred dolhJ, (S10Q) or less.) - — DISTRICT NO PROCESSEP By rJ 1 certify that In the performance of the work for which this AIR HANDLING UNIT,CFM— I cc permit is Issued, 1 shall not employ any person In any manner !ZM O so as to become subject to the rkers'C mpen. ion aws. BOILER, BTU _ �� I APPROVALS DATE INSPECTOR'S SIGNATURE W �Date,!��i pplicant U COMPRESSOR,BTU N ROUGH _, , NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM Exemption, you should become subject to the Workers' FINAL Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall he deemed revolted. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT 9 (commencing with Section 7000)of Division 3 of the Busi- I WALL / ness and Professions Code, and my license is i full force and 60 7 effect. �� j License Num be Lic.Class I ContractoJALDate.f —//— . , I am exempt Am the licensing requirements as I am a licensed architect or a registered professional engineer Plan check fee 2546 of above. _— acting in my professional capacity (Section 7051, Bus- iness and Professions Code). i PERMIT ISSUING FEE$ ,S Lic.or Reg.No. Date I TOTAL FEE e HOWIE OXVNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's NAME License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): f4DDRESS 1, as owner of the property, will do the work and the CITY TEL. NO. structure is not intended or offered for sale (Section r.7 7044, Business and Professions Code). ❑ OWNER U /�� r; 0 0 0 0 0 3 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (MAIL (Section 7044,Business and Professions Code). ADDRESS IoA _ , f , �,0o �h5p CONSTRUCTION 1.FNDING AGENCY CITY /J��p-� TEL.NO(j ( 0 0 I hereby affirm that there is a construction lending agency f/ d for the performance of the work for which this permit is GONTRACTO on / y 7 , _n 2 issued(Sec.3097,Civ. J � � L Lender's Namr —_- _ �/ ADDRESS '(A, Lender's Address FIT TEL.NO. 't- s--- — lei I certify that I have read this upplication and state that the above information is Correct.I agree to comply with all County LICENSE NO. C AS ordinances and State laws regulating Heating, Ventilating and Air Co n'Itg d h eby au horice representatives of this SEE REVERSE FOR EXPLANATORY LANGT AGF Co u n r up the • ove-mentioned proper,} Jr__ / hl. Cti s L _ ` Ignature of Date ��r` WORKERS'COMPENSATION DECLARATION CE °'S7C (2-80) A P P LL= CAT�®II'V' FOR P E rR WT I hereby affirm that I have a' certificate of consent to self . , insdre, or a certificate of Workers'Compensation Insurance,o'r HEATING-VENTILATING-AIR G-VENTILATING-AIR CONDITIOPt9ING a c&rtA#j.edepy tJ1eseo��(Sec.3800,Lab.C.) Policy+No. `` [.�ffooJJCYCobomppany ac-m-InAll— E] Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUIL C Af�D S�► ETY Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN /� BUILDING gay [ Date d �`- ApplicantIb i -1JC' (PRINT OR TYPE ONLY) ADDRESS ��y~t�IJ1GMj� LOCALITY PLC CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE NEAREST } (This section need not be completed if the work involved ABSORPTION UNIT,BTU CROSS ST. 0 by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. P a v 0 I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM— permit FM permit is issued, I shall not employ any person in any manner f� C so as to become subject to the Workers'Compensation Laws. BOILER,BTU— APPROVALS D ! AP �& PROV4ALS1, E I PECTDR'S SIGNATURE W Date Applicant . COMPRESSOR,BTU 0 ROUGH �� ta!) NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL �� rk_-_ 0e Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must fortis- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be �� deemed revoked. FURNACE: FAU GRAD LICENSED CONTRACTORS DECLARATION 4S FLOOR: BTU I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT 9 (commencing with Section 7000)of Division 3 of the Busi- WALL ness and Professions Code, and my license is in full force and effect. License Number 36045 44 Lic.Class z Contractor �',2Jd�te ElI am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer Plan check fee 25%of above. acting in my professional capacity (Section 7051, Bus- iness and Professions Code). PERMIT ISSUING FEE$1 7M Lic.or Reg.No. Date I TOTAL FEEd �j - HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that 1 am exempt from- the Contractor's NAME' iLt 1(Z License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): ADDRESS i ❑ 1, as owner of the property, will do the work and the i,H p � TEL.NO. " �O structure is not intended or offered for sale (Section CITY {�1 O KITCLA I — 7044, Business and Professions Code). I o 0 6 0 7 A I, as owner of the property, am exclusively contracting OWNER I�as�laU ._ S �V � 1L_ with licensed contractors to construct the project I MAIL ^� # 0 0 0 0 0 (Section 7044,Business and Professions Code). ADDRESS UZZ I V-11- N( LO CONSTRUCTION LENDING AGENCY CITY )�i~ /4�/p TEL.NO. !BI J 2 - 30700 I hereby affirm that there is a construction lending agency I A �� ,= � ��Q for the performance of the work for which this ermit is CONTRACTOR ^7�3��i---y- ►rt� L issued 'Se . 3097,Civ.C.). ADDRESS Cj0 Lender's Name Lender's Address CITY r -TEL.NO. rn01LT� l.�-1�?� �ex, I certify that I have read this application and state that the STATE LIC. J ry�y6 f above information ,correct.I agree to comply with all County LICENSE NO. CLASS ` f " ordinances and S ute laws regulating Heating,Ventilating and it Conditioning. an hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE Co to note u on the above-mentioned properly for _ specti n purpos s. It S gn ture of er 't D e