HomeMy Public PortalAbout6162 ROSEMEAD BLVD_Mechanical__ OR�N ceCdM ENSATION DECLARAT16fV -80) pp
CE-818 (2 P76A364C AP ER
MQT
v
I +eir?b9lt*firm
that I have t certificate of consent to self
in,par4, or��certifioate of Workers'Compensation Insurance,or ,
a cer�lfied.copythereof•(Sec3800 Lab.C.) Iq�� I4�R►TIWC's-NEWTIL�►TI Gi"AIR CIOW/®�IjVI�jOLi/VII G;
Pol)c No.Lrv�=fsf: miff Y 6J�s.CSA. D� IfV� —
Certified copy is hereby furnished. COUNTY OF LOS ANGELES I BUILDING AND SAFETY
Certified copy is filed with the county buildin 'ins ection I
g P IBUILDING
de tme t FOR APPLICANT TO FILL IN _
mw
Date Applicant (PRINT OR TYPE ONLY) ADDRESS
• LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE L
COMPENSATION INSURANCE NEAREST
(This-section need not be completed if the work involved ABSORPTION UNIT,BTU (CROSS ST. d
by the permit is for one hundred dollars ($100) or less.) bISTRICTNO: PROCESSV BY U
I certify that in the performance of the work forwhich this AIR HANDLING UNIT,CFM I �� x Cc
permit_is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER,BTU I O
APPROVALS DATE IN5PE5OR'S GN TURE U
Date Applicant COMPRESSOR,BTU ROUGH yl IL
NOTICE TO APPLICANT: 'If, after making this Certificate of VENTILATION SYSTEM r W
Exemption, you should become subject to the Workers', FINAL ZZA Z
Compensation provisions of the Labor Code,you must forth-I, EVAPORATIVE COOLERVAL
with comply with such provisions or-this permit shall be I I. IDA ION
deemed revoked. FURNACE: FAU RAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: B U
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Sectio'e 7000)of Division 3 of the Busi� WALL
ness and Professions Code, and my license is in full force andel
effect. jjao ! 2 1 1 a 4 A
License Number Lic.Class_ Q SS I # 0 0,0 0 0 8
Contractor Date
ElI o e4aoo
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineePlan check fee 25%of above. 0 0 0 4 1RQ 0 r=
acting in my professional capacity (Section 7051, Bu-
iness and Professions Code). i PERMIT ISSUING FEE$ Q Q 12 06—; 84
Lic.or Reg.No. Date f� TOTAL FEE a
HOME OWNER-BUILDER DECLARATION I PLAN CHECK APPLICANT
t
I hereby affirm that I am exempt from- the ContractorN NAME
License Law for the following reason (Section 7031.5, Bulf-
ness and Professions Code): , ADDRESS
F1 I, as owner of the property, will do the work and tgIe
structure is not intended or offered for sale (Section CITY TEL.NO.
7044, Business and Professions Code).
OWNER L
I, as owner of the property, am exclusively contracting ey
with licensed contractors to construct the proje t MAIL
(Section 7044,Business and Professions Code). ADDRESS l Y
CONSTRUCTION LENDING AGENCY CITY27;A2 d TEL.NO.
I hereby affirm that there is a construction lending agen y CONTRACTOR
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.).
Lender's Name ADDRESS
Lender's Address CITY 17 TEL.NO.
I certify that I have read this application and state that the STATE LIC.
above information is correct.1 agree to comply with all Cou ty LICENSE NO. CLASS
ordinances and State laws regulating Heating, Ventilating d
Air Conditioning, and hereby authorize representatives of t is SEE REVERSE FOR EXPLANATORY LANGUAGE
Count to enter Pon the above-mentioned property 'or
insp r s
Signa ure of a mittee a