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HomeMy Public PortalAbout4930 BALDWIN AVE_Mechanical__ WORKERS'COMPEiNSATION DECLARATION CEA 818 (2-80) \ PFUC A V�O N G��o G�3 G'C R WT - I hereby affirm that I have a' certificate of consent to self insure, or a certificate of Workers'Compensation Insurance,or HFATMG;-ZlENTILATING-Al R, _C0NDIT'I®G 1HG a c -tff coop,thereof(Sec. 31300 Lab.C.) 8 O`7?333 �",a.... Policy No. c'ompanyywell, lh _ v�ru�7 COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished. —' Certified copy is filed with thecounty building inspection F(��g ,�,PP1:6CAfilT TO (FILL IN BUILDING department. 7���• p II ADDRESS Date Z t S[_ Applicant �� ' (�� (PRINT OR TYPE ONLY) LOCALITY' CERTIFICATE OF EXEMIPTION FROM WORI{ERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE NEAREST } (This section need not be completed if the work involved ABSORPTION UNIT,BTU CROSS ST. IL by the permit is f3: ore ftundred dollars ($100) or less.) DISTRICT NO, / PROCESS' By I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM ,i F/ r O permit is issued, I shall not employ any person in any manner a v o so as to become subject to the Workers' Compensation Laws. BOILER, BTU I-_ APPROVALS DATE INSPECTOR'SSIGNATURE 0U Date.. Applicant I COMPRESSOR,BTU —_'v�G—r'� L)o a ROUGH ��� ° N NOTICE TO APPLICANT: If, after making this Certificate of � VENTILATION SYSTEMr FINAL z Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- I{ EVAPORATIVE COOLER VALIDATI©N with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVIT FLOOR: BTU.�L Gt` 1 LICENSED CONTRACTORS DECLARATION / �— IL 0 I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT 9 (commencing with Section 7000)of Division 3 of the Busi- WALL ness and Professions Code, and my license is in full force and (' 3 effect. Lf�d Q License Number- 7( Lie.Class C7 0 Contractor— Date I am exempt from the licensing requirements as I am a 1 licensed architect or a registered professional engineer Plan check fee 25%of above. acting in my professional capacity (Section.7051, Bus- yt �� PERMIT ISSUING FEE$ iness and Professions Code). Lic,or Reg.No. Date TOTAL FEE r 7 tw HOME OWNER-BUILDER DF,CLARATION PLAN CHECK APPLICANT I hereby affirm that 1 am exempt from- the Contractor's- NAMET�; License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): I ADDRESS ` f `7 ® I, as owner of the property, will do the work and the # o 01'0 o 4.1 structure is not intended or offered for sale (Section CITY / TEL. NO. vc�12QC� ( i 7044, Business and Professions Code). J 2 A 0 2 7, Q Q ❑ OWNER I, as owner of the property, am exclusively contracting with licensed contractors to construct the project MAIL G /a '0 0 0 2 a Q a (Section 7044, Business and Professions Cade). ADDRESS �j 3 ✓Ce"44 ( fi CITU—Ii.4 TEL.NO. _f O 2 1 8?8 1 CONSTRUCTION LENDING AGENCY � I hereby affirm that there is a construction lending agency CONTRACTOR ,,, for the performance of the work for which this permit is /�' / issued.(Sec. 3097,Civ.C.). Lender's Name ADDRESS 15 7—:37 Lender's AddressCITY— 7 rF TEL.NO:��� I certify that I have read this application and state that the STATE (y LIC. above information is correct.I agree to comply with all County LICENSE NO. J 0 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 insnection purpo-.s. Signature of Permittee Date