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HomeMy Public PortalAbout5540 BALDWIN AVE_Mechanical__F- - WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT 1 hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec. 3800, Lab`C. 76A364C CE-818(REV. 10/81) Policy No. J Company Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Pol ItJCI Certified copy is filed with the count,building inspIK (PRINT OR TYPE ONLY)FOR APPLICANT TO FILL IN BUILDING / sr tion department. AD DateDRESS 1 Appl ica LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE ` CERTIFICATE OF EXE PTION FROM RKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED v the permit is for one hundred dollars ($100)or less.) ` x AIR HANDLING UNIT, CFM l/U U I 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 become subject to the Workers'Compensation Laws. IBOILER, BTU APPROVALS DATE INSPE OR'S SIGNATURE COMPRESSOR, BTU ( ROUGH Date Applicant 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 forth- VA ION with comply with such provisions or this permit shall be deemed revoked. / FURNACE: FAURAVITY LICENSED CONTRACTORS DECLARATION / FLOOR BTU d 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. d {} } License Number � � tic. Class<1152 , U Contr �� Date U I am exe under Sec. MA Plan check fee 2 6 7 9,7 R 9- B.&P.C. for this reasonz PERMIT ISSUING FEE $ .S� �-r 0.0,0m 8 0 Date: _ ' Signature TOTAL FEE � ) .•,® 4 Q,5 Q OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License ► o © a 4 5 d Law for the following reason (Section 7031.5, Business and NAME Professions Code): 4,0 3 e 8 7 ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and CITY TEL. NO. the structure is not intended or offered for sale(Section 7044, Business and Professions Code). OWNER ❑ 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 CONSTRUCTION LENDING AGENCY CITY ��j��j/'✓' TEL. NO` /Zg I hereby affirm that there.is a construction lending agency for the performance of the work for which this permit is issued CONTRALTO( (Sec. 3097, Civ. C.). ADDRESS Lender's Name J� / c�� CITY f ��jT✓ TEL. NO. �//3 Lender's Address a / STATEQ� LIC. 1 certify that 1 have read this application and state that the LICENSE NO. �j CLASS above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby aut orize representatives f th' County to enter upon the e-mentdone ropert in ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of App liaa or Agent Date