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HomeMy Public PortalAbout5453 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 COUNTY OF LOS ANGELES BUILDING AND SAFETY F1 Certified copy is hereby furnished. ❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion department. ADDRESS (PRINT OR TYPE ONLY) t Date Applicant LOCALITY I NO. TYPE OF APPLIANCE OR EQUIPMENT FEE _ 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. PR7ES D BY the permit is for one hundred dollars ($100) or less.) AIR HANDLING UNIT, CFM 4' I certify that in the performance of the work for which this e OJ permit is issued, I shall not employ any person in any manner so as 10 become subject to the Workers' Compensation Laws. ,BOILER, BTU APPROVALS D14 INSPECTOR'S SIGNATURE Date Applicant COMPRESSOR, BTU , ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL - E Exemption, you should become subject to the Workers' / Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER 9 ID with comply with such provisions or this permit shall be deem- ed revoked. FURNACE: FAU 7�J;V� 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 C7e„�.�' ® 010. O Contractor Date �/ ❑ 1 am exempt under Sec. Plan check fee IW B.&P.C. for this reason. ®- PERMIT ISSUING FEE $ �' 1A Date: Signature TOTAL FEE w OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and NAME Professions Code): s __. _ F] 1, as owner of the property, or my employees with ADDRESS ' *.I n� n a wages as their sole compensation,will do the work and a r f,9_II; the structure is not intended or offered for sale(Section CITY TEL. NO. 7044, Business and Professions Code). sj ED01 OWNER I, as owner of the property, am exclusively contracting 5- ��i with licensed contractors to construct the project (Sec- MAIL 11_I i A�,L 5. -3 - � — tion 7044, Business and Professions Code). ADDRESS � c CONSTRUCTION LENDING AGENCY CITY TEL. NO. `HEC'�' I hereby affirm that there is a construction lending agency for aJ- CHANGE _ s the performance of the work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C.). ADDRESS Lender's Name 'l�i 9{:-_1_1_9] `_7 � Ll CITY TEL. NO. Lender's Address l qq-, STATE LIC. � � n�1 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 laws relating to building construction, and hereby authorize representatives of this County to enter upo bove-mention p perty for in tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE • v. Si ature of Ap icant or Agent Date ©s