HomeMy Public PortalAbout5616 BALDWIN AVE_Mechanical__ (2) W(rJRKER-'COMPENSATION DECLARATION 7i ►9C(2-80) APPLICATION FOR PERMIT
I hereby affirm that 1 have a' certificate of-consent-to self '� I
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDIT°-=c:
a certified copy thereof(Sec. 3800, Lab.C.)
Policy No. Company
Certified copy is hereby furnished.
COUNTY OF LOS ANG EL+- BUILC�.i'.i D SAFETY
Certified copy is filed with the county building inspection 'BUFOR APPLICANT TO FILL IN -AD LD
department. SS /
y
Date Applicant (PRINT OR TYPE ONLY) ADDRESS
LOCALITY-
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE -
COMPENSATION INSURANCE NEAREST J }
(This section need not be completed if the work involved ABSORPTION UNIT, BTI CROSS ST. � �/ 0
by the permit is for one hundred dollars (5100) or less.) DISTRICT NO._ // PROCEB D U
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 "G� 0
so as to become subject to the Workers' Compensation Laws. BOILER, BTU
APPROVALS DATE INSPECTOR'S SIGNATURE lU
Date Applicant COMPRESSOR, BT.0 ROUGH CL
NOTICE TO.APPLICANT: If, after making this Certificate of VENTILATION SYSTEM 0 ty.. Z
Exemption, you should become subject to the Workers' FINAL r
�J —
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be EVAPORATIVE COOLER VALIDATION
deemed revoked.
FURNACE: FAU - GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm.that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and e+� �a
effect. S �j�W
License Number Lic. Class
Contractor Date
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan Check fee 25% of abov .
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE $
Lic.or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from- the Contractor's NAME 2 5 Q 4,6 R
License Law for the following reason (Section 7031.5, Busi- # e 4
ness and Professions Code): ADDRESS
I, as owner of the property, will do the work and the 2 • s 2 7, 0
structure is not intended or offered for sale (Section CITY TEL. NO.
7044, Business and Professions Code). S LVj Is 0,0 2 7 O Q H
F-1OWNER G. �
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL ` P Q:l3 0-8
(Section 7044, Business and Professions Code). ADDRESS =9G JL a 4 I dll;, ✓il
CONSTRUCTION LENDING AGENCY CITY + j, TEL. NO.
I hereby affirm that there is a construction lending agency CONTRACTOR i
for the performance of the work for which this permit is
issued (Sec. 3097,Civ.C.).
Lender's Name ADDRESS
Lender's Address CITY
I certify that I have read this application and state that the STATE LIC.
above information is correct. I agree to comply with all County a LICENSE NO.' CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above-mentioned property for
inspection pp �vi:.c--
.IJP _
Signature of Permitte Date