HomeMy Public PortalAbout5009 KAUFFMAN AVE_Mechanical__ \,YORKER'S'COMPENSATION DECLARATION.. 720-0046 6A364C DPW 9/89
QI>✓PUCQMN ®R pERMT LIME ., GREENhereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy hereof(Sec.3800 Lab. C.)
Policy No. Company COUNTY'OF LOS ANGELES' DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
El Certified copy is hereby furnished. rVl e r C
q f
Certified copy is-filed with the county building inspection FOR A PRINT NT OLBUILDING FILL IN ADDRESS J o I rV; �'G[ (A ►1/'( .(f
department_ ( OR ONLY)
Date 7 Applicant a /ES NO. .TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY — -.a , '•/u
CERTIFICATE OF EXEMPTION FROM WORKERS'' NEAREST.
CROSS ST.'..
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit:is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
.: I,certify that:in the performance of the work for which this permit` DISTRICT NO.' PROCESSED BV'
is issued, I shall not employ any person in any.manner so as to BOILER,BTU y
become subject to the Workers'Compensation Laws. � ®
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S''SIGNATURE'
Date Applicant- - VENTILATION SYSTEM .
NOTICE TO APPLICANT: If, afte'r making this Certificate of ROUGH,
Exemption,you should'liecome subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor,Cod-e, you must forthwith comply with such' FINAL ✓
provisions or this permit shall'be deemed revoked.' FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU �7 VALIDATION
I hereby affirm that'I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencingwith Section 7000) of'Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect:.,
414 df�
License Number if 2- b 2 Lic.Class �-a
Contractor Date - V
OPlan check fee
l am.exempt under Sec. �` O
B.&P.C.for this reason ' PERMIT ISSUING FEE$ ACCT.a
Date: TOTAL FEE 3307 '!`b 7t' d
9
Si nature -
CDPLAN CHECK APPLICANT -
OWNER-BUILDER DECLARATION Z
I hereby'affirm*that I am exempt from the Contractor's License Law NAME 4 kS-
for the following reason (Section,'7031.5, Business and Professions D 1 JTEt is
Cade): ADDRESS _ ` _,
I,'as owner'of the property, or my employees with wages' .. ai
Tr►TAL �''
as their-sole compensation, will'•do the work and the CITY TEL.NO. r•�-1 93.96
structure is not intended or,offered for sale (Section 7044, CHECK
Business and Professions Code). OWNER1 1 `� o (•ttttltV ,I�� r
I, as owner of the property, am exclusively contracting MAIL F`
with licensed contractors to construct the project (Sec- ADDRESS" 3 ()o C? 0 A. t'V\ Ci
tion 7044, Business and Professions Code). _ r T
CITY - / TEL.NO. c {- i/' r �
CONSTRUCTION LENDING AGENCY 2 r�ii L 'T Z 6 �' 6
I hereby affirm that there is a.construction lending agency for ! D 7500 AM 11' 2
it
the performance of the Work for which this permIs issued CONTRACTOR O
(Sec.3097,Civ.C J. < �.lv _
ADDRESS 20 `OSE° e POrw�
Lender's Name /
CITY /,' s'/; TEL.NO.t7 ?`J— q�l 7
Lender's Address STATE L LIC.
certify that,I have read this application and state that the above LICENSE NO. 7— (o-•Z (3 CLASS �— <D
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 insp ction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
'StEMATURE OF APPLICANT08 AGENT DATE - -