HomeMy Public PortalAbout4916 1/2 BALDWIN AVE_Mechanical__ WORKER S COMPENSATION DECLARATION 20 DD46DPW
76A364APPLICATION FOR PERMIT LIM& E GREEN
76A364C
I h%Cby affirFthat I have a certificate of consent to self Insure
or certificate of Worker s Compensation Insurance or a certified HEATING VENTILATING-AIR CONDITIONING
copy there (Sec 3800 Lab C)
Policy No Company' �90C131 COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
Certified copy is hereby furnished
B DING
Certified copy Is filed with the county build g inspectl FOR APPLICANT TO FILL IN ADDRE S ��J I/�
departmen (PRINT OR TYPE ONLY)
Date25 Applicant LOCALITY Cie-7 ] / h
NO TYPE OF APPLIANCE OR EQUIPMENT FEE l CJI
NEAREST
CERTIFICATE OF EXEMP N FRO RKERS 5 y CROSS ST �l.)JC�_�
COMPENSATI INSURA E a
COMPEN UNIT BTU ASSESSOR ' ' 1�
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less) AIR HANDLING UNIT CFM
� DISTRICT NO PROCESSED BY
certify that in the performance of the work for which this permit
is Issued I shall not employ any person in any manner so as to BOILER BTU
become subject to the Workers Compensation Laws
COMPRESSOR BTU 000it
t, J APPROVALS DATE INSPECTORS SIGNATURE
Date Applicant l , VENTILATION`SYSTEM
NOTICE TO APPLICANT If after making this Certificate of ROUGH
Exemption you should become subject to the Workers Compensation EVAPORATIVE COOLER
,provisions of the,Labor Code you must forthwith comply with such FINAL 04=,400
provisions or this permit shall be deemed revoked a FURNACE f FAU G�p VITY {{ �-3-115
LICENSED CONTRACTORS DECLARATION_ FLOOR BTU S 0 OV (G VODATION
I hereby affirm that I am licensed under provisions of Chapter 9{ HEATER SUSPENDED UNIT r — Y — --
(commencing with Section 7000) of Division 3 of the Business and WALL 'Q g /0 O
Professions Code and my license is In full force and effect t T ' e C ;JO V T
t ^� v ypppJ_������»'��`u���� ''' �_f _ ACC °JrL
License Number )�d� Llc Class i f � �*/`7 10 r(3 �$Y M3303 105.70
Contractor_ Date
C th I IJ R 1 ITEMS �a
❑ I exerts under$ c Plan check fee TOTAL �-�`-"'° ®��
B&P C for this reason PERMIT ISSUING FEE $ 7 D
CHECK' 10 t°70 0
DateTOTAL FEE Q CHANGE °0U
Signature ' r W
PLAN CHECK APPLICANTco
OWNER BUILDER DECLARATION M ' ` G/pt z
0000-0001 4/2� 70 Z
* I hereby affirm that I am exempt from the Contractors License Law NAME y Ln °
for the following reason (Section 7031 5 Business and Professions /"�^ � OV75} 1 F`r{ °01
Code) ADDRESS6-3 l
M 1 C 4
❑ I as owner of the property or my employees with wages / `
" as their sole compensation will do the work and the CITY,ii T L NO
structure is not intended or offered for sale (Section 7044 V
Business and Professions Code) OWNER 1�
❑ I as owner of the property am exclusively contracting MAIL i�
_
with licensed contractors to construct the project (Sec ADDRESS a,
s tion 7044 Business and Professions Code) - 0
CITY Y ,v TEL NO 0y _S
CONSTRUCTION LENDING AGENCY 1
Ihereby affirm that there,is a construction lending agency for CONTRACTOR
A the performance of the work for which this permit Is Issued , —
(Sec 3097 Civ C) r
ADDRESS
Lender s Name r l�
" CITY n/1 f TEL NO
Lender s Address STATE LIC
I certify that I have read this application and state that the above LICENSE NO CLASS
information is correct I agree to comply with all County ordinances
and State laws rel ing to buildinq construction and hereby authorize v
representatives f this Cou o enter upon the above mentioned #
propert or specti n p oses } SEE REVERSE FOR EXPLANATORY LANGUAGE '
SIGNATy E OF APr
_70rt AGENT DATE