HomeMy Public PortalAbout5546 BALDWIN AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I h �„ that I have a certificate of consent to self
insure, _rtificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a cert:,'.'cc; th reo_f (Sec. 3800, Lab. C.) CE-81 C
�_ �L(E� e� CE-818(REV. 10/81)
Policy No any a
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
ti In cl ar ment. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY i
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FIR WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. J
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars ($100)or less.) n
AIR HANDLING UNIT, CFM
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. BOILER, BTUAPPROVALS DATE INSPECTOR'S SIGNATURE
Date ApplicantCOMPRESSOR, BTU j /0 a ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL ✓ /l
Exemption, you should become subject to the Workers'
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: FAUG A ITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED-UNIT-
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect. .�+
0.
License Number __P59� Lic. Class 60 a3 0
Contractor Date 4c
❑ 1 am ex pt under Se•
Plan check fee Ld
B.&P.C. for this reason PERMIT ISSUING FEE $ �� Ste. �
Date:
TOTAL FEE �
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT O -- ••
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): "vt
❑ ADDRESS I, as owner of the property, or my employees with g,
wages as their sole compensation,will do the work and ANT•
the structure is not intended or offered for sale (Section CITY TEL. NO. �
7044, Business and Professions Code). 33A7 ITEMS ` .I
30
OWNER /�3 g �� 1
ElI, as owner of the property, am exclusively contracting _
/ _
with licensed contractors to construct the project (Sec- MAIL ADDRESS t
(�'��
tion 7044, Business and Professions Code). - - TOTAL '�'34.00
CONSTRUCTION LENDING AGENCY CITY •'<1TEL. NO252?_-
r "' ' ;`4
I hereby affirm that there is a construction lending agency for gni fP C` ,� -�D CHECK .00
the performance of the work for which this permit is issued CONTRACTOR G Cam .00(Sec. 3097, Civ. C.). -
P
ADDRESS
Lender's Name CITY ld LG NO.
jT TEL. NO. DODO-coot B 10/
89
Lender's Address c� 5�0�•�2�r {qM� �+,:2
STATE LIC. /i �,:L1a7 � 1'Fil Ver,..
1 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
upon tFue above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatar�of Applicant or Ag t Date