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Home My Public Portal About5303 BALDWIN AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT hereb�< affirm that I have a certificate of consent to self Insure,. or a certificate of Workers' Compensation Insurance; HEATING - VENTILATING - AIR CONDITIONING W, q cer`ifi.ad copy thereof (Sec. 3800, La i _ , 76A364C. C.), � �Y 20-0046 DPW 9/88 061icy No. { Company ❑ Certrfied 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 tion department. ADDRESS , �,��3 /r 5'/l/� , (PRINT OR TYPE ONLY) LOCALITY Date Applicant` NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEM ON FROM WORKERS' NEAREST COMPENSA. N INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. 0/ PROCENZEk BY the permit is for one hundred dollars ($100) or less.) I a 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 so as to become subject to the Workers' Compensation Laws. BOILER, BTU APPROVALS DATE NSPECTOR'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 VALIDA' with comply with such,provisions or this permit shall be deem- ed revoked.. FURNACE: FAU GRAVITY 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. J _J G/ rOZ Lic. Class License Number O Contractor )"At/Date ❑ O I am exempt under Sec. Plan check fee u W B.&P.C. for this reason. H Date: PERMIT ISSUING FEE $ Z TOTAL FEE ; Signature ER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby offirt t I am exempt from the Contractor's License Law for The owing reason (Section 7031.5, Business and NAME L o 1� , Professions Code): w- ❑ I, as owner of the property, or my employees with ADDRESS A CCT s wages as their sole compensation,will do the work and CITY TEL NO. 7 i ? r� the structure is not intended or offered for sale(Section l,r..2 7044, Business and Professions Code). OWNER ❑ I, as owner of the property, am exclusively contracting I ITEMS with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS . TOTAL :12 25 CONSTRUCTION LENDING AGENCY CITY TEL. NO. CHECK 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR ��:� , CHANGE °I-I(•) (Sec. 3097, Civ. C.). � � - ��yi/� Lender's Name ADDRESS SrlU�l�0 i q / 7'`�%G9%� Lr�IV�t LlT 6/�'vi' CITY TEL. NO. Lender's Address C 65"77 1 An 9:2.9 STATE LIC. 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 up�thecve-mentioned pro riy for inspection purposes. /� SEE REVERSE FOR EXPLANATORY LANGUAGE �SI ature of Applicant or Agent Date ©s