HomeMy Public PortalAbout6276 ROSEMEAD BLVD_Mechanical__ WORKERS'COMPENSATION DECLARATION n PPn C n �� N FOR PERMPT
I liVreby affkm that I have a certificate of consent to self � l�il L� l�(�' I]�f �P
• Insure, or a certificate of Workers' Compensation Insurance, ,aA3eac .HEATING
=-VENTILATING - Alts CONDITIONING
or a certified copy thereof (Sec 3800, Lab C )
/ CE-818(REV 10/81)• •• - ' -
Policy No Company "tom' '
COUNTY OF-LOS ANGELES BUILDING AND SAFETY
❑ certified copy is hereby,furnished
Certified copy is filed with the county building inspec- FOR APPLICANT-TO FILL IN BUILDING :)
tion department (PRINT OR TYPE ONLY) ADDRESS 4
t
Date ' ! Applicant LOCALITYNO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION F06M WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST
w
(This section need not be completed if the ork involved by ABSORPTION UNIT, BTU DISTRICT NO PROCESSED BY
the'permit is for one hundred dollars ($100)or less.)•
AIR HANDLING UNIT,CFM U
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 become subject to the Workers'Compensation Laws I BOILER, BTU APPROVALS DATE I)SP912fis SIGNATURE
Date Applicant COMPRESSOR, BTU 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 .� VALIDATFdJk
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 7�D J "� Llc Class ��� D V
Contractor Date ^� �2 6 Q 2 A O
LU
Plan
I am exempt under Sec _ _ _ #,0 0 0 0 2 2 W
Plan check fee H
B 8P C for this reason PERMIT ISSUING FEE $ 1 0 0•1 650 Z
Date - _
Signature TOTAL FEE (7 'a a a 1 6 5 0 v
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License 0 a 0 7 ar 8 5
Law for the following reason (Section 7031 5, Business and NAME'
Professions Code)
❑ I, as owner of the property, or my employees with ADDRESS
A 21b
wages as their sole compensation,will do the work and CITY TEL NO
the structure is not intended or offered for sale(Section
7044, Business and Professions Code)
OWNER ,
E] 1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL -
tion 7044, Business and Professions Code)
ADDRESS 2 6 OAA
A
CONSTRUCTION LENDING AGENCY CITY TEL NO I
I hereby affirm that there Is a construction lending agency for D
the performance of the work for which this permit is issued _ _ #,o o•o a o 8
p p CONTRACTOR -
(Se'c 3097, Civ C ) ��� �h _
ADDRESS V r !L/�LQ (c, ;I , a 4 5.0
Lender's Name
CITY TEL NO��[/ �07 rJ- _ *'a 043,5050
Lender's Address r
STATE _3C(
.^� LIC 0 8 07.785—
I certify that I have read this application and state that the LICENSE NO L� LIC
above information Is correct I agree to comply with all County
ordinances and State jaws relating to building construction,
and hereby authorize representatives of this County to enter '
upon the above-mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatu f Applicant or Agent Date