HomeMy Public PortalAbout6269-6271-6273-6275 ROSEMEAD BLVD_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I Hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, 7eAaeac HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.)
CE-818(REV. 10/81) 'a
Policy No. Company
Certified copy is.hereby furnished. COUNTY OF,LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building lnspec- FOR APPLICANT TO FILL IN BUILDING /' ti / V.
f�� ML��q�
tion department. (PRINT OR.TYPE ONLY) ADDRESS tJ E'� aQ5; 1 t
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE �
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CU g 07"
BTU
(This section need not be completed if the work involved by ABSORPTION UNIT, DISTRICT No. ROCESSED BY
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the permit is for one hundred dollars ($100)or less.) ./�x
1 certify that in the performance of the work for which this AIR HANDLING UNIT,CFM .J v lJv
permit is issued, I shall not employ any person in any manner BOILERBTU
so as to become subject to the Workers'Compensation�La ,Laws. � APPROVALS DATE INSPECT R'S SIGNATURE
Date��, QApplicant � � `✓ 1 � COMPRESSOR, BTU 1;{ O ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION 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,and
my license is in full force and effect.
License Number /tLiic�. Class
Coractor 1Y��� L�1 ��s�r Dafe
I am exempt under Sec. � � �
,p, Plan check fee C.
B.&P.C. for this reason'��; (.151��' PERMIT ISSUING FEE
.4 411ULrDate:
TOTAL FEE
Signature- $ 3'8 Q 9 A
OWN R- LDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I xempt from the Contractor's License # o o 0 o o 8
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the property, or my employees with' ADDRESS �} COOW ( o o (G tj 0
wages as their sole compensation,will do the work and s ' 0 0 - 4 Q 5 0 70:
the structure is not intended or offered for sale(Section CITY jpw TEL. NO.
7044, Business and Professions Code). 8
❑ OWNER � d�15� O 1. 1.3 _ 6
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a.construction lending agency for pop,performance of the work for which this permit is issued CONTRACTOR ��GL �s
(Sec. 3097, Civ. C.).
Lender's Name ADDRESS
Lender's Address CITY TEL. NO. 76
"
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. 3� CLASS
above information is correct. I agree to comply with all County
ordinances and S e laws ret ting to building construction,
and hereby out r' e repres totives of this County to enter
upon the `olve ntioned p perty for nspection rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
.ig atu of Applicant or Agent Date