HomeMy Public PortalAbout6156 ROSEMEAD BLVD_Mechanical__ ION
WOthat I have
a certificate
of consent to 76M64 DPW 9/89 APPLICATION FOR PERMIT LIME GREEN
78A364C
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.)
Policy NgCompanyQy„ COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
BUILDING
Certified copy is filed with the county buildin inspection FOR APPLICANT TO FILL IN ADDRESStZ.
ai G
department. (PRINT OR TYPE ONLY)
Date It-n � �-Applicant LOCALITY _ /gyp!� �r
-� NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST l
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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED
^BV
�
I certify that in the performance of the work for which this permit
is issued, 1 shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL �7-.9
provisions or this permit shall be deemed revoked. FURNACE: FAU GBAVITY a/ VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU d!G
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect. f
License Number,4 C��_Lic.Class 7_
Contractor Data-�tip� a _q a , (C,'
❑ I am exempt under Sec. Plan Check fee a
B.&P.C.for this reason PERMIT ISSUING FEE$ / L
Date: TOTAL FEE E
Signature Cr
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
1 hereby affirm that I am exempt from the Contractor's License Law NAME , 131
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS AC% I o 3
❑ 1, as owner of the property, or my employees with wages .,_-7lk!
as their sole compensation, will do the work and the CITY TEL.NO. ?i 127.[1"
structure is not intended or offered for sale(Section 7044, ITEMS
Business and Professions Code). OWNER A PVe-a0o MM.j/Xj � a��127. 00
�� -a a-5,t�
❑ 1, as owner of the property, am exclusively contracting MAIL /A �J� � TOTAL 1 2 S' a �P0
with licensed contractors to construct the project (Sec- ADDRESSvf 7, IF- 60t._Ve v& t� 11,,
tion 7044,Business and Professions Code). .y---- CHECK 127 a l}I I
CONSTRUCTION LENDING AGENCY CITY f y f? TEL.N07 0 CHANGE
I hereby affirm that there is a construction lending agency for
I he performance of the work for which this permit Is Issued CONTRACTOR �`e �� ,
(Sec.3097,Civ.C.). ADDRESS, 6 �� VC Pd_ A 1 1310
-131101 11/20/912 1#2L/912
Lender's Nam a 4
CITY,,gJfV?0.,TO q t 7 33 TEL.NO.'3_gig . I 3948 1 AM 10 o i1�i
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO.� 7�[S�J CLASS G
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 inspectp u r aaes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIG N KTAWOF APPLIC
rt ANT OR AGENT DATE