HomeMy Public PortalAbout6022 ROSEMEAD BLVD_Mechanical__ WORKER'S COMPENSATION DECLARATION 2"046 DPW 9/89 LIMEI GREEN
hereby affirm that 1 have a certificate of consent to self insure,
APPLICATION FOR PERMIT
or a certificate of Worker's Compensation Insurance,or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
Policy No. 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 BUIL SG A �C� D� 2 '�
department. /J (PRINT OR TYPE ONLY)
//✓� 2 gn LOCALITY /+
Applic �Y�, ' �—°' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE G."
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS
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($100)or less.) AIR HANDLING UNIT CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU; Lf
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such' FINAL
provisions or this permit shall be deemed revoked. �, FURNACE: FAU ITY �� // Z! VALIDATION
LICENSED CONTRACTORS DECLARATION 1 / FLOOR BT (v 7
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and affect.
/ .2
// � moi` J
License Nunli�//� � Lic.Class' Z® ACCT,s }
C46 llto"r7� /Date 3307 4229.60
❑ I am.exempt under sec. Plan check fee 1 ITEMS+
BAP.C.for this reason PERMIT ISSUING FEE$ TOTAL 429 m 603 H
Date: TOTAL FEE CHECK 42?.61'11 I`j,
Signature PLAN CHECK APPLICANT CHANGE .01) U,
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason(Section 7031.5, Business and Professions 11/ 5/92 Code): ADDRESS t
t1ixJ iJ 1
❑ 1, as owner of the property, or my employees with wages 634.88 f AN 10 45
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 y TEL.N
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 r
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name CI Y TEL.N 0-6-5
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE No CLASS r�
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 or i�ectio ^ SEE REVERSE FOR EXPLANATORY LANGUAGE
�
31 A RE OFAPPLICANT OR AGENT DATE