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HomeMy Public PortalAbout6128-6138 ROSEMEAD BLVD_Mechanical__ ..,:R s'COMP ENSATION DECLARATION CEA$6 SC(2-BO) APPLICATION FOR P E R Y�7tl T F.01i'cy ,; :,rr,rm.thatI Ithve a certificate of consent to self 4. rtif)cafe of Workers'Cont ensation Insurance,ofd y tl sre (Sec.3800,Lah CI-IEATII�IG-bEWTILATIWG-Alli CONDITIOi�111�G o � omPanY— IPA- - Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ert,fied copy is filed with the county building inspection �hj AA partm nt FOR APPLICANT TO FILL IN BUILDINGADDRESS �6 Date!Lpplicant (PRINT OR TYPE ONLY) CERTIFICATE OF EXEMPTION FROM WORKERS' LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE mow' COMPENSATION INSURANCE NEAREST _ (This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. 7�i•�clC by the permit is for one hundred dollars (5100) or less.) DISTRICT NO. PPROCES, DI certify that in the performance of tate work for which this AIR HANDLING UNIT,CFM � ,.` Ix ` permit is issued, I shall not employ any person in any manner V O so as to become subject to the Workers' Compensation Laws. BOILER,BTU A INF- APPROVALS DATE ZS#CTO S SI ATURE tU li Date Applicant COMPRESSOR,BTU / CL ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL '�� r 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 ti deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR: BTU e„ 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 V Lic.Class Contra for AT —z 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 Q 5-0 Lie.or Reg.No. Date TOTAL FEE ? t HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANTIYA I hereby affirm that I am exempt from- the Contractor's NAME ` License Law for the following reason (Section 7031.5, Busi- _ t ?=r# �_;fLl ness and Professions Code): ADDRE S EJ I, as owner of the property, will do the work and the - - ''- structure is not intended or offered for sale (Section CITY TEL.NO. 7044,Business and Professions Code). , / ❑ OWNER 9%© �eL,fCr I, as owner of the property, am exclusively contracting with licensed contractors to construct the project MAIL p�� �sl c i;i T'I •`'% (Section 7044,Business and Professions Code). ADDRESS 4 )ar; r�I �0-� yey __ .._.. i _ CITY' �Ll TEL.NO. �p G� __ _ rl'ty:•�s CONSTRUCTION LL'NDING AGENCY - I hereby affirm that there is a construction lending agency , for the performance of the work for which this permit is CONTRACT R - C issued(Sec.3097,Civ.C.). Lender's Name ADDRESS Aae3 Lender's Address CITY TEL.NO.1,4 4C-4-- - I certifythat I have read this application and state that the �) Pp STATE LIC. r above information is correct.I agree to comply with all County 11 LICENSE NO. LASS ordinances and State laws regulating Heating, Ventilating and Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXANATORY LANGUAGE County to enter upon the above-mentioned property for t inspection u poses. r Signature 6f Permittee Date 76A364C O R PERMIT WrJRsl;EltS'CC?MPyL'NS�TION DECLARATION CE-818(2-80) APPLICATION F I+h ��fl< hat I nave ji• certificate of consent to self i+es a"or a c rtificate of Workdrs'Compensation Insurance,or (-(EATING-VENTILATING-AIR CONDITIONING certified copy'theredr(Sec.3800,Lab.C.) I Policy N.I Company �� I I E] Certif d copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the unt building inspection BUILDING /-�2 CIn a � Y FOR APPLICANT TO FILL IN f? 7 / ��i�Y� Date (Applicant (PRINT OR TYPE ONLY) ADDRESS LOCALITY r CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE , . NEEjREST I CROSS ST. (This section need not be completed if the work involved ABSORPTION UNIT, BTU d by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSED Y V I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM /�Q�, permit is issued, I shall not employ any person in any manner v((,,JJ e Cr so as to become subject to the Workers' Compensation Laws. BOILER, BTUO • V APPROVALS D TEAICT&SAIIGNA3 V Date ApplicantCOMPRESSOR,BTU �0 d ROUGH d NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM Exemption, you should become subject to the Workers' FINAL / Z Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY - LICENSED CONTRACTORS DECLARATION FLOOR: BTU 0 0 I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT 9 (commencing with Section 7000)of Division 3 of the Busi- I WALL ness and Professions Code, and my license is in full force and effect. 3 ! License NumberLic.Class Contracta Date ❑ I am exempt from the licensing requirements as I am a _ licensed architect' or a registered professional engineer Plan check fee 25%of above. ' acting in my professional capacity (Section 7051, Bus- iness and Professions Code). PERMIT ISSUING FEE Lic.or Reg.No. Date TOTAL FEE HOME OWNER-BUILDER DECLARATION P AN CHECK APPLICANT11,J- I hereby affirm that I am exempt from-the Contractor's N ME -_ a License Law for the following reason (Section 7031.5, Busi. 1 ..ess and Professions Code): AD ESS' s '=.I.• ❑ I, as owner of the property, will do the work and the _ `I structure is not intended or offered for sale (Section CITY TEL.NO. -• •� 7044.Business and Professions Code). Q - OWNER 7 /L 07k I •:.- I, as owner of the property, am exclusively contracting ❑ with licensed contractors to construct the project 'MAIL (Section 7044,Business and Professions Code). ADDRESS :CITY2� l TEL.NO. Q'l$" CONSTRUCTION LENDING AGENCY + I hereby affirm that there is a construction lending agency i for the performance of the work for which this permit is CONTRACT R _ aviie issued.(,Sec. 3097,Civ.C.). ) r Lender s Name `4DDRESS Lender's Address CITY if TEL.NO. ��� I certify that I have read this application and state that the $TATELIC. + above information is correct.I agree to comply with all County LICENSE NO. CLASS } ordinances and State laws regulating Heating,Ventilating and !1 Air Conditioning,and hereby authorize representatives of this I SEE REVERSE FOR EXPLANATORY LANGUAGE i Ir County to enter upon the above-mentioned propert for ! ' O]� iinspection pur y l + Signature of Pe mittee Date