HomeMy Public PortalAbout6332 ROSEMEAD BLVD_Mechanical__ y affirm tS'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, . HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800; Lab. C.) 76A364C
/meq y CE-818(REV. 10/81)
Policy NNolf! `1Nlj. 5-OCIompanyC0r1%m ti;AA 1A.r\1caA S^5-
1�4JI Certified copy is"hereb'febrnished. COUNTY OF LOS ANGELESBUILDING AND SAFETY
Certified c5p'y is'filed.with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS
(PRINT OR TYPE ONLY)
DateAppliccm ? T/" LOCALITY 1Q;
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE T
CERTIFICATE OF EXEMPTION FROM ORKERS' NEAREST
COMPENSATION INSURAN E CROSS ST.
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU M DISTRICT NO. PRO ED B
the permit is for one hundred dollars ($100)or less.) He—At ""^ 3 4,i 0OC+ uQt!
) i
�
AIR HANDLING UNIT, CFS fy
I certify that in the performance of the work for which this � v
permit is issued, I shall not employ any person in any manner
so as to,become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGN TURE
Date Applicant COMPRESSOR, BTU ROUGH
v
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' vi
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N
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.
f` 11L
License Number /a 1 7v 30_ Lic. ClassC-2-0 , V
_ ag
Contractor Date f_ 0
❑ 1 am exempt under Sec. �
Plan check fee �
B.BP.C. for this reason PERMIT ISSUING FEE $ �d Z
'Date:
Signature
TOTAL FEE 5
OWNER-BUILDER DECLARATION PLAN CHECK 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):
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code).
OWNERt 1.0•#
I, as owner of the property, am exclusively contracting t
❑, /J ">� G ' Q_�I�► ,�U
with licensed contractors to construct the project (Sec- MAIL \ i
�:.
tion 7044, Business and Professions Code). ADDRESS 0
CONSTRUCTION LENDING AGENCY CITY F i1 TEL. NO. d Ll y
I hereby affirm that there is a construction lending agency for u - e u C °�Zlp, '�
the performance of the work for which this permit is issued CONTRACTOR '0
(Sec. 3097, Civ. C.). L r i bn� , �Q•�
v S �L 1_A •.
�e tM i LP
Lender's Name ADDRESS ,
CITY C0.f$G CA J(py r TEL. NCyrA13)e
Lender's Address o���
STATE �� LIC. `
I certify that I have read this application and state that the LICENSE NO. f �+ CLASS Cj'�V.
above 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
on theabove-mentioned operty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of plicant or Agen Date .