HomeMy Public PortalAbout5421 BALDWIN AVE_Mechanical__ WORKERS COMPENSATION DECLARATION CEA 8B18C(2 80) A P L'rc-:-'UC A T I®N FOR PERMIT
1 hereby,affirm that I have a certificate of consent to self
41nsurr, or a-%certificateof Workers Compensation Insurance or HEATING-VENTILATING-Alba CONDITIONING
cert)ReV copy thereof(Sec 3800 Lab C)
4
Policy No Company
Certified copv is hereby furnished
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county budding inspection FOR APPLICANT TO FILL IN BUILDING ��77
department �qy� ADDRESSv�
Date- 10- pplicant� ` �"Q�`a-�f (PRINT OR TYPE ONLY) —
'T�/T LOCALITY
CERTIFICATE OF EXLMPTION FROM WORKERS 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 0a
by the permit is for one hundred dollars ($100) Or less) / 015TRICT NO PROCESSED BY 0
1 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 ✓ O
so as to become subject to the Workers Compensation Laws BOILER BTU 1-
APPROVALS DATE INS r_CTOR S IG ATURE U
Date Applicanta-
COMPRESSOR BTU ROUGH ��
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL / Z
Exemption you should become subject to the Workers
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VALID T
with comply with such provisions or this permit shall be
deemed revoked FURNACE FA I — RAVITY —Al.ICENSED CONTRACTORS DECLARATION FLOOR BTU (�U
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
effect a :5
License Number
/� / �Lie Class_&
Contractor j'."G z2 ✓ - Date�7-lam CSloG
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above
acting ,in my professional capacity (Section 7051 Bus
iness and Professions Code) PERMIT ISSUING FEE $
Lie or Reg No Date TOTAL FEE
HOME OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractors NAME T�-�
License Law for the following reason (Section 7031 5 Busi ;24995A
ness and Professions Code) ADDRESS 7iZ2j?j (,(J�(jl/C1 S/
I as owner of the property will do the work and the CITY " 41 "� '�' TEL NO'/1 # • • • • ° 8
structure is not intended or offered for sale (Section 4--77
7044 Business and Professions Code) 1 ° • 3 Q 50
DOWNER �,`�/{ moo
I as owner of the property am exclusively contracting I -/ /� ^ • ° • 3 0 5 0 c=�
with licensed contractors to construct the project MAIL �!7/ /L!✓�_�J���
(Section 7044 Business and Professions Code) ADDRESS �-r-`-i �•J Q 710-860 1 0-8 6
CONSTRUCTION LENDING AGENCY CITY `T �+ _ TEL NO
I hereby affirm that there is a construction lending agency CONTRACTOR
for the performance of the work for which this permit is JTZ/
issued (Sec 3097 Civ C)
Lender s Name ADDRESS IW Z/ ��J
Lender s Address CITY C14T NO /�?)
I certify that I have read this application and state that the STATE zz LIC
above information is correct 1 agree to comply with all County LICENSE NO J��6 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
❑1S Prtinn OSeS
Signatur of Permittee Date