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HomeMy Public PortalAbout5319 BALDWIN AVE_Mechanical__ (2) a WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT by affirm that I have a certificate of consent to sof -p orla certificate of Workers{Comperuation Insurance, o certified copy thereof (Sec. 3800, Lab. C.) 76A364C HEATING - VENTILATING - AIR CONDITIONING Q� 20=0046 DPW 9/88 Pdli ?zlo,T_Company 13 Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY El Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion department. ADDRESS g o41—/./ 1,W 4b1Lr - (PRINT OR TYPE ONLY) 'Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY ��f77BLC GSI T CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (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.) I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM 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 SIGNATURE Date Applicant COMPRESSOR, BTU�� J ROUGH f? rNr C D NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, 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 deem- ed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION 2 FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business HEATER: WALL. and Professions Code,and my license is in full force and effect. } License Number Lic. Class , ,t 0 O U Contractor .Date sIM =T O ❑ I am exempt under Sec. H Plan check fee `'=`'z, 6 f S , B.BP.C. for this reason. I IT•`I`�� H PERMIT ISSUING FEE $ Z Signature Date: TOTAL FEE -1� TCI-.IAL a @ �, O OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT CHECK 61,E,1I{ I hereby affirm that I am exempt from the Contractor's License CHANE Law for the following reason (Section 7031.5, Business and NAME w6 _Chute 0 Professions Code): n I, as owner of the property, or my employees with ADDRESS 3 � ge,Id inJ!/r'1 V`Q wages as their sole compensation, will do the work and �+ is 71-' the structure is not intended or offered for sale (Section CITY re� e Ct, _6 TEL. NO.(T($)W'z :p1)' 2971 1 AN O,�. i=.t'r 7044, Business and Professions Code). OWNER VU6h ❑ I, as owner of the property, am exclusively contracting - CAunn L04- with licensed contractors to construct the project (Sec- MAIL t tion 7044, Business and Professions.Code). ADDRESS .J.3 QR/1_ Ot JVoi V'e CONSTRUCTION LENDING AGENCY CITYTSL,, l2 C� TEL. NO.(818) VV2- oy7 1 hereby affirm that there is a construction lending agency for loop performance of the work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C.). ADDRESS Lender's Name CITY TEL. NO. Lender's Address hAATIv- I certify that I have read this application and state that the STATE VLIC. LICENSE NO. CLASS 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 upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ti a Signature of Applicant or Age Date ©s