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HomeMy Public PortalAbout5438 BALDWIN AVE_Mechanical__ (2) WORKERS' 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 20-0046 DPW 9/88 Policy No. Company F-1 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(PRINT OR TYPE ONLY) tion department. ADDRESS `f �AZ, 6ALD c-v �1 /n L A Date Applicant ✓ Ci NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY nd 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, CFMI 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 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 VAL D 1 / with comply with such provisions or this permit shall be deem- v ed revoked. FURNACE: FAU 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 lic. Class 0 Contractor I (�A� Date f � , 1J 0 • I am exempt under Sec. OI.- Plan check fee u B.BP.C. for this reason. H Date: PERMIT ISSUING FEE $ -V Z Signature t TOTAL FEE OWNER- UILDERCLARATION PLAN CHECK APPLICANT I hereby affirm that I am exemp rom the Contr4Bsiness is License 01110.Law for the following reason lection 7031.5, and NAME Professions Code): I ❑ 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). OWNER :5HU;A.f 27 } I, as owner of the property, am exclusively contracting I 4r !_ with licensed-contractors to construct the project (Sec- MAIL L tion 7044, Business and Professions Code). ADDRESS �.� 1 A/G•1S 1 j /av2r 1 s 1 En-,:) CONSTRUCTION LENDING AGENCY CITY V TEL. NO. C ( �i�(E I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR �' �/US (f(e��j�� , Nth;t `,%I'! (Sec. 3097, Civ. C.). ADDRESSr -� S , V_ �e�C-Z t•�'li-CHANGE ,C-1113Lender's Name CITY [�( TEL. NO. Lender's Address ` ` > I I certifythat I have read this application and state that the STATE (z_(i� UC. f�111€g'j-1.10111;, 9/10/90 pp LICENSE NO. YY''77 CLASS above information is correct. I agree to comply with all County �_; f A. ordinances and State laws relating to building construction, �:'7 t s fibs and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signatu of App giant or 6.fe ©s