HomeMy Public PortalAbout5033 BALDWIN AVE_Mechanical__ (2) WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 APPLICATION FOR PERMIT LIQ . AREEN
76A364C
I hereby affirm tlxat I have a certificate of consent to self insure,
or a certificate of worker's Compensation Insurance, or a certified HEATING - VENTILATING -AIR CONDITIONING
copy thereof(Sec.3800 Lab. C.)
Policy NoF�-"VJ5'2 Company � �����' COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING a
department. pp t - (PRINT OR TYPE ONLY) ADDRESS �,�'' �iv
Date _l Applicant ! V L �JLOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE ABSORPTION UNIT,BTU CROSS ST.
(This section need not be completed if the work involved by the ASSESSOR
MAP BOOK PAGE ].PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU ��O
become subject to the Workers' Compensation Laws. n Q
COMPRESSOR,BTU
- APPROVALS DATE .INSPECTOR'S SIGNATURE.
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAUX GRAVY
LICENSED CONTRACTORS DECLARATION, FLOOR BTU '`J J V LIDATION
I hereby affirm that'I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencirig with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code, and
—tmy license is in full force and effect. � L+PiI�L�.GCftia Q
License Number Lic.Class
' CL
CL
Contractor /+/� /J� Data 12 3I ^ O
❑ u
lam exempt under;Sec. Plan Check fee • Ata.� a �
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B.&P.C.for this reason PERMIT ISSUING FEE$ �,S -,r{ in7c O
3
Date: TOTAL FEE cq�' jf Y r U
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Signature 1 I EMS
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT TtITA 102- 75
I hereby affirm that I am exempt from the Contractor's License Law NAME , CHECK 11�.%c
for the following reason (Section 7031.5, Business and.Professions
Code): _ s
ADDRESS H•�` rtP�GE .00
I
ElI, as owner of the property, or my employees with wages
as their. sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044;. / I !pp
Business and Professions Code). OWNER. 1 1,11 -! Ili 1 24 7+i'
I, as owner of the property, am exclusively contracting MAIL 8849 1 AM11'-49
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY jjy��_ ._ G7f� TEL.N09
I hereby affirm that there is a construction lendingagency for CONTRACTOR ,���/� �w ��C ►
the performance of the work for which this permit Is issued
(Sec. 3097,Civ. C.)
1K/
ADDRESS
Lender's Name
CITY%o(,/t/ TEL.NO.'5j
✓ S3/j
Lender's Address STATUE LIC.
I certify that I have read this application and state that the above LICENSE NO. 1��� Z�-L� CLASS
—
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 upon the above-mentioned
pr r inspectio. purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE.
SIGNATURE OF-APPLICANT OR AGENT DATE -