HomeMy Public PortalAbout6148 ROSEMEAD BLVD_Mechanical__ WORKER'S COMPENSATION DECLARATION DPW
7GA364APPLICATION FOR PERMIT LIME GREEN
76A384C
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.) -L--A "d
i
Policy No Oq(-3 Company 4 nv°✓f[e.�— ST �`- 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 pection FOR APPLICANT TYPE TOFILLIN BUILDING
S
department. ( Y)
Date — Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that In the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU Q
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU G VITY r
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license Is in full force and effect. �7 .-g_ &
� �p -
License Number �,� _LiD.Class C'~��/
� , IL
Contractor �1'11�"t<I 6I.v�Date
El Plan check fee
I am exempt under Sec. �
B.&P.C.for this reason PERMIT ISSUING FEE$
Date: TOTAL FEE LTJ
ID.
Signature 07
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z
v
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason(Section 7031.5, Business and Professions 4•
A i-L i{
rT °a'Y
Code): ADDRESS
ElI, as owner of the property, or my employees with wages 3307 1y7°t i;i
as their sole compensation, will do the work and the CITY TEL.NO. qrS
-�•
structure is not intended or offered for sale(Section 7044, s r 1:?
Business and Professions Code). OWNER C PLO �� � "�€ 1.2 00
❑ 1 IA
I, as owner of the property, am exclusively contracting �j �` _ {'� C 1ry�
with licensed contractors to construct the project (Sec- I ADDRESSO -2 v 6 tu. �� t� `.HC•C .t °01I
tion 7044,Business and Professions Code). r 8 •�¢ CHANGE [Irl
CONSTRUCTION LENDING AGENCY I CITY -�-- p � TEL.NO. �? 7,�)7 L f1 ■
I hereby affirm that there is a construction lending a�ency for CONTRACTOR ,�■w,____
the performance of the work for which this permit s issued
(Sec.3097,Civ.C.). f�0i i --l�I Its 11f?I 1 �3
ADDRESS 9 t p� i
Lender's Name ! 'e V I 3�j 1 50 AM 110
CITY S. � . 19 U,4� TEL.NO.`3�O-'
Lender's Address STATE p y LIC.
I certify that I have read this application and state that the above LICENSE NO. p ( CLASS
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 for it sp on urpos . SEE REVERSE FOR EXPLANATORY LANGUAGE
SI E OF%PPLICANT OR AGENT Or ATE