Loading...
HomeMy Public PortalAbout4904 KAUFFMAN AVE_Mechanical__ • � WORKERS'COMPENSATION DECLARATION Qpp��CA0 TDON FOR If"LSII�IIV11� Il I•hereby affirm that I have a certificate of consent to self ,insure, oraa certificate of Workers' Compensation Insurance, HEATING - bENT1LATING - AIS CONDITION ING or a certified copy thereof (Sec. 3800, Lab. C. 76A364C CE-818(REV. 10/81) Policy No.l Q 4 7 Q ti_L-C8*anyvtat(4 'js' — ❑ -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 .4904` Kaufman -Date $/.1 $/$9 Applicant PYRAMITY RITILDER3 LOCALITY Tem le Cit NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION-INSURANCE CROSS ST. Lower* AZl.1Sa CEBY (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROSSE the permit is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM QU permit is issued, I shall not employ any person in any manner so as to become subject to the War kers'Compensation Laws. BOILER;BTU APPROVALS DATE INSPECTOR'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 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 9HEATER: SUSPENDED UNIT'(commencing with Section 7000) WALL.of Division 3 of the Business � and Professions Code,and my license is in full force and effect. / I '/�� DLlCr ©axe j fes, d License Number 400289 Lic. Class : R /`/ D V SY5Tti� PYRAMID B LI'MERS 8.11 8'/RA O Contractor - ❑ I am exempt under Sec. d Plan check fee N 6.8P.C. for this reason' � PEWIT-ISSOING FEE I- Date: TOTAL FEE Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License D p' Low for the following reason (Section .7031.5, Business and NAME PY Professions Code): ICToV ❑ ADDRESS I, as owner of the property, or my employees with 16332.'E. San' Bernardino Rd. wages as their sole compensation,will do the work and CITY TEL. NO3307 12°25 the structure is not intended or offered for sale(Section .COUiTl'a 9 6 7. 1342 * 1zT 7044, Business and Professions Code). OWNER .-Fe.tner F1I, as owner of the property, am exclusively contracting MAIL - TOTAL �' c25 with licensed contractors to construct the project (Sec- ADDRESS 4 9 0 4� Kaufman CHECK, 1 tion 7044, Business and Professions Code). i .255 CONSTRUCTION LENDING AGENCY CITYTem le Cit' TEL. No.285 7228 GHANA eOCI I hereby-affirm that there is a construction lending agency for the performance of the work for which this permit is issued ' CONTRACTOR D (Sec. 3097, Civ. C.). Lender's Name - ADDRESS 16332. .E. San. Bernardino'' Rd. 0000-0001 8/28/89 7777 i CITY TEL. NOJJ- 1• Ffl 1 V 0.54 Lender's Address Covina 9 6 ], ] 3 4 2 I certifythat I have read this application and state that the STATE CL pp LICENSE NO. 400289 CLASS -B 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 property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE _ 8/18/89 Signature of Applicant or Agent _. Date, - '