HomeMy Public PortalAbout6152 ROSEMEAD BLVD_Mechanical__ ION
WORKER'S I have
a certificate
of consent to ,��84C PW 9/89 APPLICATION FOR PERMIT LIME GREEN
I hereby affirm that I have a certificate of consent to self insure,
or certificate of Worker's Compensation Insurance,or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.) i
Policy No(4C2� 40 Q Company?W)to,If QZ= , e 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 ss 6ILDING • r s G
department. (PRINT OR TYPE ONLY)
Date 1'C3,q:M 0 Applicant �— LOCALITY i� lee `(
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
46-1 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($100)or less.) I AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED SV
I certify that in the performance of the work for which this permit
is Issued, I shall not employ any person in any manner so as to BOILER,BTU Q
become subject to the Workers'Compensation Laws. i d
COMPRESSOR,BTU00 ,
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER f„sil�
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
1 hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,
and my license Is In full force and effect. l
License Number Sr —Lic.Class IC
AC f-f/?'t 14y1 /� ✓le //— �'—a a
Contractoy� 0
❑ I am exempt under Sec. .J ! Plan check fee
B.&P.C.for this reason PERMIT ISSUING FEE$ O
Date: TOTAL FEE &Iy p a
Signature
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION _; Z
I hereby affirm that I am exempt from the Contractor's License Law NAME ►
for the following reason (Section 7031.5, Business and Professions ACCT, s
Coe): ADDRESS
I, as owner of the property, or my employees with wages ' � � 7
°II�
as their sole compensation, will do the work and the CITY TEL.NO. I ITEMS
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). OWNER � (a p TOTAL 127 m LL 0
❑ I, as owner of the property, am exclusively contracting
AIL
with licensed contractors to construct the project (Sec- ADDRESS ;LO (��Z/ (� p CHEICK 127°00
tion 7044,Business and Professions Code). (CITY M ��y� L.NO.3 33 t[�ANGE o I�
CONSTRUCTION LENDING AGENCY "`
I hereby affirm that there is a construction lending agency for •CONTRACTOR H ,
the performance of the work for which this permit Is Issued j4/r/� /�
(Sec:3097,Civ.C.). ADDRESS /1�� I-V r 011100- I0 I j+1 _
vl _1 4.__1 ���(l.OLj
Lender's Name /} i�Ti' 1 ( [`� I�4_il
'CITY gl`I3gL.NO.
Lender's Address 'STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. 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 ins ae, purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ff— DA fi b
ION
0
F AGENT DATE