HomeMy Public PortalAbout6030 ROSEMEAD BLVD_Mechanical__ WOQKER'SCOMPENSATION DECLARATION 7OM66DPWg/es APPLICATION FOR PERMITLIME GREEN
I he eby� aTfirm that I have a certificate of consent to self insure, 78A364C
or a certificate of Worker's Compensation Insurance,or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C�) nY" ` � " u
Policy No. C 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 BUILDING 1�O I G
dppartment. //�j �}� (PRINT OR TYPE ONLY) ADDRESa[? [/
Dat.IA-5-9 Applicant` s-+' � • NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY G+
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST .117
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT.BTU ASSESSOR
(This section need not be completed If the work involved by the MAP BOOK PAGE PARCEL
permit Is}or one hundred dollars($100)or less.) I AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
1.5 COMPRESSOR,BTU 6
APPROVALS DATE INSPE R'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Z- ---
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY �
LICENSED CONTRACTORS DECLARATION FLOOR BT VWA
' LIp7A�TION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT [9—ZTCL3
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
License Numb441 `4 77,6 5F LID.Class v �� ' e
ACCTos >
33017
D '04- G Dat6 3 49o60 cc
I ❑ Plan check fee 1 ITEMS
I am exemptnder Sec. Q
! B.&P.C.for this reason PERMIT ISSUING FEE$ 7 TOTAL 429 a 60 H
J Date: TOTAL FEE CHECK ` oI�n
Signature CHANGE t[l V
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
1 hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason(Section 7031.5, Business and Professions , I� �-01701
Code): ADDRESS i J_■ 5/92
❑ I, as owner of the property, or my employees with wages 6349 1 AM111.046
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). OWNS
❑ 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).
CONSTRUCTION LENDING AGENCY CITY TEL.NO �s
linformation
hereby affirm that there is a construction lending agency for CONTRACTOR ►
he performance of the work for which this permit Is Issued
Sec.3097,Civ.C.).
ADDRES
ender's Name
CITY ender'sAddress STATE / LIC.
certify that I have read this application and state that the above LICENSE N CLASS is correct. I agree to comply with all County ordinancesnd State laws relating to building construction,and hereby authorize
epresentatives of this County to enter upon the above-mentioned
ttopert f P inspection rppses. SEE REVERSE FOR EXPLANATORY LANGUAGE
RE F APPLICANT OR AGENT DATE