HomeMy Public PortalAbout5131 BALDWIN AVE_Mechanical__ (2) WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hei;*, affrrm that I have a certificate of consent to self `
"insure or a certificate of Workers Compensation Insurance HEATING VENTILATING AIR CONDITIONING
CE 81
or a certified copy thereof (Sec 3800 Lab C ) C
CE 818(REV 10/81)
Policy No Company
❑ Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec FOR APPLICANT TO FILL IN - BUILDING �/� j Ale
ti
Tion department (PRINT OR TYPE ONLY) ADDRESS / O/Wy A
Date Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE CROSS ST od f1 e.
(This section need not be completed if the work involved by ABSORPTION UNIT BTU DISTRICT NO / PROCESSED BY
the permit is for one hundred dollars ($100)or less ) n
AIR HANDLING UNIT CFM �L�_ J AUC
I certify that in the performance of the work for which this _
permit is issued I shall not employ any person in any manner BOILER BTU ���� � �� r
so as to become subject to the Workers Compensation Laws APPROVALS DATE PECTOR S SIG TORE
i
Date Applicant ! COMPRESSOR BTU ROUGH
NLIW4T If after maki� this Certificate of VENTILATION SYSTEM FINAL
Exemption you should become sub ct to the Workers
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VALIDAT 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
USPENDED UNIT WALL
(commencing with Section 7000) of Division 3 of the Business >_and Professions Code and my license is in full force and effect O.
O
License Number Lic Class U
OC
Contractor Date 0
❑ I am exempt under Sec W,
Plan check fee N
B 8P C for this reason PERMIT ISSUING FEE a A I Z
Date
Signature TOTAL FEE
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 7s
PP fessions Code) V
t'
� I as owner of the property or my employees with ADDRESSS / ACCTA
wages as their sole compensation will do the work and
the structure is not intended or offered for sole(Section CITY TEL NO �7 3307 44a0
7044 Business and Professions Code)
OWNER 1 ITEMS
❑ I as owner of the property am exclusively contracting
with licensed contractors to construct the project (Sec MAIL
ADDRESS _ TOTAL ' ' ��
tion 7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY CITY TEL NO CHECK 44.011
1 hereby affirm that there is a construction lending agency for (�j�
the performance of the work for which this permit is issued CONTRACTOR /�� , .00
(Sec 3097 Civ C )
ADDRESS
Lender s Name 6/13/39
Lender s Address CITY TEL NO - - 3932 1 AM 9:19
STATE LIC
I certify that I have read this application and state that the LICENSE NO CLASS
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
� -/ 4y,P7 -
Signature Applicant or Agent Date