HomeMy Public PortalAbout4918 KAUFFMAN AVE_Mechanical__ WORKER'S COMPENSATION. 720-0046 6A364C PW 9/89 n PPUCA�� N '�®� ���rx���
hereby aff rm }hat.I have a'certrflcate of consent to self,insure, C� �I u�u
* ;< CONDITIONING.
. or a ce�,ifiiClste of v�arker s.Compensation Insurance, or a certified HEATING--.VENTILATING-AIR'
copy thereo{(Seo 3800 Lab C.)
i Policy No. Company: COUNTYOF`LOS ANGELES-, DEPT'OF PUBLIC WORKS BUILDING AND SAFETY DIV:
,:.
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Certified copy is hereby furnished.
cAunyinCertified opy is flied'with theg inspecti n FOR APPLICANT TO FILL'IN gDDREBS (� i
depa(t nt. - (PRINT OR TYPE ONLY)
_ '+ •_ �A '!�'
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT,' FEE LOCALITY /16y%
b FITI17 CATE OF.EXEM CROSS SL ,.
COMPEN TION FROM WORKERS' (f'7
SATION INSURANCE " ABSORPTION UNIT,BTU
NEAREST f• / /J
• '
(This section need not be completed if,the work involved bythe• ASSESSOR.permit is for one hundred dollars($100 or less. DisTRicr No. PROCESSED PARGEL O/�J
MAP-BOOK PAGE
) ) AIR HANDLING UNIT,CFM D By
1 certify.that'in';the performance of.the work for vihich.this.permit
is issued, I shal not employ aoy•pe. on In ny manner,so as to BOILER,BTU "
beco410E
je to the Workers'-
become Laws. /1 p J7
COMPRESSOR,BTU . 1ILV 4 a /J��. la'
APPROVALS DATE 'INSPECTOR'S SIGNATURE
Date ApplicantVENTILATION SYSTEMNOTAP LIC'ANT: If,,a er eking this Cer ficate of ROUGH, ! '
Exemptia. you should beconie;subject'to the.Workers'Compensation EVAPORATIVE COOLER
'provisions'of the'Labor Code,.you'must,'.forthwith'comply with-such FINAL
provisions or this.permit shall be deemed revoked. FURNACE: FAU GRAVITY r
LICENSED CONTRACTORS DECLARATION FLOOR BTU �� Q VALIDATfON .•
I,hereby affirm'that I am licensed under provisions of Chapter 9 -SUSPENDED UNIT
f (commencing with Section 7000) of Division'3.:of the Business and HEATER:. WALL
Professions Code,and my license is in full force and effect.
-3 r
License Number Lic Class .
D 4i s o
Con
77-7'v e � Date
V
Plan check fee ; '
I am exempt.under Sec: Q
e,&R.C.for this reason PERMIT iSSUING.FEE$ � � t�
.. ..Date: - :
f
TOTAL.FEE. I i rIL . Wa
Signature
Pl_ NrCHECK APPLICANT,—
OWNER-BUILDER DECLARATION,
hereby affirm,that I'am exempt from;the Contractor's License Law' NAME
for the following'reason'(Section 7031.5,1 Business,and'Professions
Code): r
D
ADDRESS
�, I, as owner of the property,'or my employees with,wages`
as-,their sole, compensation, well do'the work and the CITY TEL NO
structure is hot.intended ob-.offered for sale":(Section 7044;- _ i E M n
Business and 0fofessions.Code). : OWNER
( i.
1, as owner of the property, am exclusively contracting. MAIL
with,licensed contractors to construct the'project (Sec- ADDRESS / ;,Or,
'. tion 7044,Bsisiness,and Professions Code). iE
IT ' NO
CONSTRUCTION'LENDING AGENCY
hereby affirm that there is'a construction lending agency for CONTRACTOR
the,performance,of the work for which this permit Is Issued `
(Sec. 3097, Civ.G.). D r j4-
A
f
ADDRESS s:
LendeNs Name L.
CITY- /I EL.NO. '7?_ ^
Lender's Address STATE r LIG —
I Certify that I have read this application and State that the above LICENSE NO.: _7 CLASS
information is correct. i agree to comply with all County ordinances
and State laws-relatirig to building construction,and hereby authorize
representa e ofthis County to enter upon the above- /n ,d
pe0tion purposes.' SEE REVERSE FOR EXPLANATORY LANGUAGE
GNATIj OF APPLICANT OR AGENT - DATE, - - - -
L ..