HomeMy Public PortalAbout6011-6015 ROSEMEAD BLVD_Mechanical__ ON
r `WORKERS'COMPENSATION tate of corse APPLICATION FOR PERMIT
I hereby affirm that 1 have a certificate of consent to self
insure, ora certificate of Workers'Compensation Insurance, 7
or a certified copy thereof(Sec. 3800, Lab. C.) 6A364C HEATING - VENTILATING - AIR CONDITIONING
CE-818(REV. 10/81)
Policy No. Company �An � v►n n-y. y
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUJWING AND SAFETY
❑ Certified copy is filed with the county building inspec- FORAPPLICANT TO FILL IN BUILDING
42-0
tion department (PRINT OR TYPE ONLY) l? f ��
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Date Applicant �. 1
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved b T,BTU
the permit is for one hundred dollars($100)or less.) Y DISTRICT NO pZ
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
^ t3 �f
permit is issued,1 shall not employ any person in any manner 7— 5
TJ ,y
so as to become subject to the Workers'Compensation Laws. BOILER,BTU APPROVALS DATE INSP CTOR'S SIGNAT RE
Date r, 2—gXPlleant S7J /� COMPRESSOR,BTU 2 p ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL J�
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA ION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU RAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect.
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License Number—4-1 [64-7 3 7 ic. Class 0
r
Contractor 0
I am exempt under Sec.
Plan check fee
B.&P.C.for this reason I.
Date:
PERMIT ISSUING FEE$ 101-17) �
Signature TOTAL FEE :5a
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME S � �
Professions Code):
❑ 1, as owner of the property, or my employees with ADDRESS
wages as their sole compeintended
off will for
the work(Se and CITY , bHIJ. 4 � .2
the structure is not intended or offered for sale Section TEL. NO.
7044, Business and Professions Code). _ 1 G 7 A
❑ 1, as owner of the property, am exclusively contracting OWNER ), ) ! L r-y! . ) i
with licensed contractors to construct the project (Sec- MAIL Vv i/ /�/ t c n o a o
tion 7044, Business and Professions Code). ADDRESS (-� W. ""e7z4r/ �t�[Y 0 o 5 0 (�
CONSTRUCTION LENDING AGENCY CITY tyf�_Z,Q t " '. '
TEL. No. Oil /Y! 'tU
I hereby affirm that there is a construction lending agency for �,� `
the performance of the work for which this permit is issued CONTRACTOR -T
(Sec. 3047, Civ. C.))�.s/�r�y ,r E/J!�3 p
Lender's Name 1..�U701" ` ADDRESS
CITY (3 TEL. NO.
Lender's Address h
STATELIC
I certify that I have read this application and state that the LICENSE NO. 6'k 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 obove-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date