HomeMy Public PortalAbout6230-6236 ROSEMEAD BLVD_Mechanical__ ��L//,jrORKERS'COMPENSATION DECLARATION .r APPLICATION FOR PERMIT
"t Herdb! gffirm"that I h.vzeacertiflcojP of content to self +� `
Insurew,81'a certificate of Workers',.Compensafion Insurance, 76A364C -J ` � HEATING - VENTILATING - AIR CONDITIONING
qr a certified copy thereof(Sec. 3800, Lab. C.) CE-818(REV. 10/81)
Policy No. Company
Cektified copy is hereby furnished. COUNTY OF 1OS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion departmen (PRINT OR TYPE ONLY) ADDRESSMill
'
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
RTIFICATE OF EXEMPT ROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved by ABSORPTION UNIT,BTU DISTRICT NO. 107
PROC SED
the permit is for one hundred dollars($100)•or less.)
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner. Q
so as to become subject to the Workers'Compensation Laws. BOILER,BTU APPROVALS DATE INSPEC R'S SIGN URE
Date Applicant COMPRESSOR,BTU ROUGH r�
NOTICE TO APPLICANT: If, after making this Certificate of YENTILATION SYSTEM FINAL Z
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VAI IDAT
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU ITY �O
LICENSED CONTRACTORS DECLARATION Z_ FLOOR BTU
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 WALL
and Professions Code,a dmy license is in full force and effect.
�a O
License Number Lic. Class — , V
Bd 09
Contractor r i r Date
❑ I amexe t under Se LU
Plan check fee
B.BP'.C. for this reason' H
PERMIT ISSUING FEE0 �
Dat
Signature TOTAL FEEa�
OWNER- HECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ,
Law for'the following reason (Section 7031.5, Business and NAME
Professions Code): r
❑ ..A. as owner of the property, or my employees with• ADDRESS r
wages as their sole compensation;will do the work and �4CT�a
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code). y .sod
OWNER � tT��
❑ I, as owner of the property,am exclusively'contracting A�
with licensed contractors to construct the project (Sec- MAIL
ADDRESS TI�TAL3535. 50
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY, TEL. NO. CHECK 35o50
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR !ti oil,
.01
(Sec. 3097, Civ. C.).
ADDRESS a �Lender's Name 0000' DWI 5/12/809
CITY t TEL.
Lender's Address 32-52 1 AM 9*3
STATE LIC. Q
I certify that I have read this application and state that the LICENSE NO. CLASS p�[J
above'information is correct. 1 agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon ve-mentio ed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of ADDlicani or AaPnt ate