HomeMy Public PortalAbout4851 KAUFFMAN AVE_Mechanical__ o WORKERS COMPE SATION DECLARATION
appd�C�Q��®f>vl FOR pEL3G�iv aT
l t heresyy �phfi•r�n that•I �iav a certificate of consent to.self ,
,p sb cf1�a'ceriificate of o'kers' Compensation Insurance, ;aAse4c HEATING - VENTILATING -'AIR CONDITIONING
or a cer?ified copy thereof (Sec. 3800, Lab. C.) CE-818(REV. 10/81)
Policy No. Company
Certified copy is heresy furnished. COUNTY OF LOS,ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building in,spec- FOR APPLICANT TO FILL IN BUILDING
tion-department. ADDRESS
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY �-
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 BY
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 _
permit is issued, I shall not employ any person in any manner
so as to become subject to'the Workers'Comp nsation La BOILER, BTU APPRovALS DATE NSP TOR•S,SIGNATURE
Date Applicant COMPRESSOR, BTU a ROUGH
NOTICE TO APPLICANT: If, after making this Certific to of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of thelaborCode, you must forth- EVAPORATIVE COOLER VALIDATI
with comply with such provisions or this permit shall be
,-deemed revoked. FURNACE: FAU GRAVITY
r
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDEDUNIT
(commencing'with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect. CL
0
License Number Lic. Class V
Contractor Date 0
❑ I am exempt under'Sec. LU
Plan check fee
B.&P.C. for this reason' ' U �� 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 D
Law for the following reason (Section 7031.5, Business and NAMEA 111 r 0 k. .
Professions Code):❑ ``
ADDRESS L TP ,I, as owner of the property, or my employees with
wages as their sole compensation,will do the work and Tp'
the structure is not intended or offered for sale Section CITY TEL NO.oZ
7044, Business and Professions Code).
OWNER .
I, as owner of the property, am exclusively contracting
w with licensed contractors to construct the project (Sec-, MAIL
ADDRESS N!. 5 9 2 A
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL. NO. # 0 0 0 0 0 8
I hereby affirm that there is a construction lending agency for
'_the performance of the work for which this permit is issued CONTRACTOR ' - D I ° ° 3Q 5,0
(Sec. 3097, Civ. C.). p p� t
i°c� 'r9:(d ADDRESS o °j° 3 0 5,0
Lender's Name `
CITY TEL. NO.
Lender's Address `�f E-`i 8 I 1,'J 9.-8 6
STATE LIC.
I certify that I have rea 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''`he above-me boned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
UJI
` Signature of 'pp onor Agent Date'.
l •