HomeMy Public PortalAbout5628 BALDWIN AVE_Mechanical__ I
WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I herebytaffi•rm 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 thgreof (Sec. 3800, Lab. C. 76A364C
x J�W `,j40 i13 CE-818(REV. 10/81)
Policy No. 5�G.!'2 Company lues i /�//��me;-1C�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
tion department. (PRINT OR TYPE ONLY) ADDRESS
Date ��Applicant - LOCALITYio NO. TYPE OF APPLIANCE OR EQUIPMENT /e- C,
FEE
Ju
CERTIFICATE OF EXEMPTION F OM WORKERS' NEAREST ,
COMPENSATION INSURANCE CROSS ST. L)IF0C!
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BYAn/
/
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 S 1 � ';�
permit is issued, I shall not employ any person in any manner BOILER, BTU
so as to become subject to the Workers'Compensation Laws. y APPROVALS DATE INSPEC 61,s SIGN URE
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 VAI IDAT ON
with comply with such provisions or this permit shall be 174
deemed revoked. FURNACE: FAU GRAVITY / e I r
LICENSED CONTRACTORS DECLARATION FLOOR BTU Om v c� ! 60
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(coinmencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,andmy license is in full force and effect. 9LLicense Number ff/6! 4-5'f(cam Lic. Class — ® U
7 1'8 5,'8'°R
Contractor lr Date It--
E] am exempt under Sec. #f c e • o ® 8 �
Plan check fee 9L
B.&P.C. for this reason PERMIT ISSUING FEE $ ) a 6 3 0''5 0
Date: TOTAL FEE (� • ® a 3 0.5 0
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 0 i 16-85
I hereby affirm that I am exempt from the Contractor's License / Pool
for the following reason (Section 7031.5, Business and 'NAME 7
Professions Code):
I, as owner of the property, or my employees with ADDRESS
El
wages as their sole compensation,will do the work and CITY !!' w TEL. NO.,;
the structure is not intended or offered for sale(Section —;a G b' 1 _ �S'
7044, Business and Professions Code). -
OWNER U
❑ I, as owner of the property, am exclusively contracting 1
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY` ole �` TEL. NO �
I hereby affirm that there is a construction lending agency for ` '
the performance of the work for which this permit is issued CONTRACTOR G
(Sec. 3097, Civ. C.).
ADDRESS C
Lender's Name �'-
CITY,! /t TEL. NO.�C�'�- �-
Lender's Address •J
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. leazCLASS
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 the above-mentioned roperty r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa e of Applicant or Agent Date