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Home My Public Portal About5446 BALDWIN AVE_Mechanical__ WGRKERS,,COMPENSATION DECLARATION _ 3 CE3Si 8 (c0) A P P L� C AT�®I�1 FOR If`E R Y�%U T I hereby affirm that I have a certificate of consent to self ins-ire or a`certificate of Workers Compensation Insurance or HEATING ViENTILATING-AIR CONDITIONING a certified copy therepf($eq '4800 Lab C) , Policy No Company ❑ Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county building inspection ❑ p FOR APPLICANT TO FILL IN BUILDING department F Date Applicant ' (PRINT OR TYPE ONLY) . ADDRESS LOCALITY CERTIFICATE OF EXEMPTION 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 0 by the permit is for one hundred dollars ($100) or less) DISTRICT NO PROCF ''D By U 1 certify that in the performance of the work for which this AIR HANDLING UNIT CFM ` /i Q permit is issued I shall not employ any perso any manner (1(� O so as to become subject to the W rkfU er atiSn Law`s v BOILER BTU — O APPROVALS DATE INS EC R S SIGNA URE W Datel�Applican COMPRESSOR BTU ROUGH N NOTICE TO APPLICANT If after s Certificate of VENTILATION SYSTEMZ > xemption you should become sthe Workers FINAL ._� _ ,— Compensation provisions of the Labor Code you.must forth EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be 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 Bust WALL ness and Professions Code and my license is in full force and I Q effect 7 `/L�(.� Z License Nutnber30sv Lic Class C- _,yam Y Contractor .5 WAW_ Date 4 ❑ I am exempt rom the licensing requirements as I am a y 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 Lic or Reg No Date / TOTAL FEE HOME OWNER BUILDER DECLARATION PLAN CHECK APk�' LICANT " I hereby affirm that I am-exempt from the Contractors NAME License Law for the following reason (Section 7031 5 Busi ness and Professions Code) ADDRESS ❑ I as owner of the property will do the work and the TEL NO structure is not intended or offered for sale (Section CITY 7044 Business and Professions Code) ❑ OWNER I as owner of the property am exclusively contracting with licensed contractors to construct the project MAIL (Section 7044 Business and Professions Code) ADDRESS ;2 56 a,5 A CONSTRUCTION LENDING AGLNCY CITY TEL NO ' I hereby affirm that there is a construction lending agency # • 0 0 0 • 8 for the performance of the work for which this permit is CONTRACTOR f issued (Sec 3097 Civ C. _ 10 - 4550 Lender s Name ADDRESS Lender s Address CITY - TEL NO e o 0 4T5 5 0,C& - I certify that I have read this application and state that the STATE LIC Q 1 5 i 8 6 " above information is correct I agree to comply with all County 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 toaenter � ,n the above mentioned property forin e n p ` to Signature of ittee_ Date I WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affrrm that I have a certificate of consent to self 'insure of a certificate of Workers Compensation Insurance HEATING VENTILATING - AIR CONDITIONING or'a certifidd copy thereof (Sec 3800 Lab C ) CE 818(REV 10/81) Policy No Company Certified 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 u/ a �� tion department (PRINT OR TYPE ONLY) ADDRESS /f7 /DO YE-- Date Applicant LOCALITY le NO TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS _ NEAREST COMPENSATION INSURANCE CROSS ST (This section need not be completed if the work involved by ABSORPTION UNIT BTU DISTRICT NO PRoc B the permit is for one hundred dollars ($100)or less ) AIR HANDLING UNIT CFM I certify that in the performance of the work for which this r Qd permit is issued I shall not employ any person in an manner so as to become subject to the Workers Compen aws BOILER BTU APPROVALS DATE INSPO0 FC�TOR S SIGNATURE Date Applicant COMPRESSOR BTU 1� ROUGH / ` NOTICE TO APPLICANT If after making t ertificate of VENTILATION SYSTEM FINAL Exemption you should become subject lo the Workers rff Compensation provisions of the Labor Code you must forthEVAPORATIVE COOLER VALIOATI N ti— with comply with such provisions or this permit shall be 10 deemed revoked FURNACE FAU RAVITY LICENSED CONTRACTORS DECLARATION FLOOR U U 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 } License Number-�, 7 Lic Class ` V FFJJ y OC Contractoryii S �N Date O F- I am exempt under Sec �� d Plan eck fee B &P C for this reason z Date PERMIT ISSUING FEE $ Signature TOTAL FEE OWNER BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor s License Law for the following reason (Section 7031 5 Business and NAME Professions Code) ❑ I as owner of the property or my employees with ADDRESS v wages as their sole compensation will do the work and the structure is not Intended or offered for sale(Section CITY TEL NO 7044 Business and Professions Code) OWNER �r AS ❑ I as owner of the property am exclusively contracting MAIL with licensed contractors to construct the project (Sec tion 7044 Business and Professions Code) ADDRESS ;2 5 5 3,2 A CONSTRUCTION LENDING AGENCY CITY TEL"NO I hereby affirm that there is a construction lending agency for # o a o o o 8 the performance of the work for which this permit Is issued CONTRACTOR Sri ` (Sec 3097 Civ C ) - I o - 50.50 ADDRESS n Lender s Name , Q,_-0 a r ° 505010 Lender s AddressCITY vs � 0930-86 STATE+ � 7 T /-C�� s� _ �_ CIC I certify that I have read this application and state that the LICENSE NO V - CLASS Cw� 0 - - above information is correct I agree to comply with all County ordinances and State jaws relating to building construction _ and herebyautho resentatives of this County to enter -- u n e above o d property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE c� ('-30-0 ,, Signature of Ap a ar Agent Date ' 0