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Home My Public Portal About5103 KAUFFMAN AVE_Mechanical__ f ''WORKERS'COMPENSATION DECLARATION �r��t! �� n ��^rad � ere�by•clffirm that I have a certificate of consent to self (� LL (� lON U" �Jvu Il insure, or a certificate of Workers' Compensation Insurance, HEATING `_ NENTILATING - AIR CONDITIONING or a certified copy thereof (Sec.'3800, Lab. C.) 76A364C ��_,�r� CE-818(REV. 10/81) Policy No.�_Company '51W F�AN10 Certifiedcopy is hereby furnished. COUNTY OFLos.ANGELES. BUILDING AND SAFETY Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN - BUILDING �A tion depart,ment. ADDRESS 0.3 ta+ AVe. ' (PRINT OR TYPE ONLY) Date"'I 10. 0 Applicant LOCALITY . 11r' t( Cf� NO. TYPE OF APPLIANCE OR EQUIPMENT- FEE CERTIFICATE OF EXEMPTION FROM ORKERS' NEAREST SA COMPENSATION INSURANCE CROSS SV_ LA ABSORPTION UNIT, BTU DISTRICT NO. 'PROCESSED BY - (This'section need not be completed if the woik involved by.- . the permit is for one hundred dollars ($100)or less.) AIR HANDLING UNIT;CFM (�lJ 56 1 certify that in the performance of the work for which this - Permit is issued,-I shall not employ any person in any manner BOILER, BTU so as to become subject-to'the.Workers'Compensation Laws:' APPROVALS DATE INS, R'SSIGNAT RE Date Applicant COMPRESSOR, BTU ROUGH NOTICE TO APPLICANT: If, after making {his Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to .the Workers'. Compensation,provisions'of the Labor Code, you must forth- EVAPORATIVE COOLER V LIRA ON with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions:of Chapter 9 HEATER: SUSPENDED UNIT (commencing with Section 7000) of Division 3 of the Business WALL and Professions Code,and my license is irr.full force and effect. X 1 839 : o Du<rs it 00111oH o License Number Lic. Class P D V Contractor zlt Date: - ❑ I am exempt Incler Sec. L ' Plan check fee B:&P.C. for this reasonISSUIFIG Z { PERMIT FEE,$ Date: Signdture` TOTAL FEE ' OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT' I hereby affirm that I am exempt from the.Contractor's License Law for the following reason (Section 7031.5; Business and NAME D. Professions Code): - ElI,'as owner of the'property, or my employees with ADDRESS. ' wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section CITY TEL NO. 7044, Business,and Professions'Code). OWNER El 1, as owner of the property, am exclusively contracting M SQL with licensed contractors to construct the project(Sec- MAIL ��qq 22 tion 7044, Business and Professions Code). ADDRESS V J AVS, > CONSTRUCTION LENDING AGENCY CITY TEL. NO. 571I hereby affirm that there is a construction.lending agency for r-v 05 / the performance of the work for which this permit is issued CONTRACTOR t A,*s-me P04100Q LS Ntp D (Sec. 3097, Civ. C.). // //^^. A ADDRESS �I� W- 6644 AYE Lender's Name t s Er. .>.i CITY ((JC✓ �rNf� CA. L NO..�6b S .30 Lender's Address STATE LIC. ; Icertify that I have read this application and state that the LICENSE NO. ! CLASS •_B_ // '" _ above information is correct. I agree to comply with.all County �I�7 ordinances and State laws'relating to building construction; and hereby authorize representatives of this County to enter th upon the bove-mentioned property for inspection'purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ? Signature o pplicant-or Agent - ate WORKERS'COMPENSATION DECLARATION -APP'pp pp pp (��p n(��j�/� I hereby affirm that 1 have a certificate of consent to self „CE-818,12-801 tL-y U� U U'V ®` lf�L If'�UVU�� _insure, or a certificate.oI Workers'Compensation Insurance,or _ a certified copy th�e)re:of(Sec.3890,.Lab.C.)4 T- IEATINiG NENTiLATING,-AlR CONDITIONING Policy No7! / 7�CpCompanY52 C 6—_ Ps! Q Certified copy is hereby furnished`..`, COUNTY�OF LOS ANGELES " BUILDING AND.SAFETY- Certified copy.is€ti'ed with'-the county building inspection BUILDING x� FO'R APPLICANT'TO FlLL';!N department. j A1 // Q Date�� _Appticartf_ -(PRINT OR TYPE.ONLY) ADDRESS J /O�. /V �/yG{.✓,(////! /U f/ LOCALITY• / CERTIFICATE OF EXEMPTION'FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE e/11. P �fs COMPENSATION-INSURANCE (This section need not be completed if'the work involved Ah"30RP1'ION UNIT, BTU CROSS d ST. by.the perttiit is for`ani; hundred dollars ($I00) or less.) " DiSTRICT Nog Paocess� BY I oerttfy that in-the performance of the work for which this AIR HANDLING UNIT CFM` - - peimtt is issueI cc d,i shall not-employ any person lnany.manner- 0- so as-to become subject to the Workers' Compensation-Laws. BORER,ST U "' APPROVALS DATE INSPECTOR'5SiGNATURE C) LU Date A¢plicant COMPRESSOR:,BTU' (o. Q oo �® f G. --� _ ROUGH: _ :a CA NOTICE TO APPLICANT: If, after triaking this Certificate.of f' VENTILATION SYSTEM �.� �? " ' z Exemption,. you should--become subject to the -Workers' : . FINAL -:•-. . with complywthisions of the Labor Code, you must forth- EVAPORATIVE COOLER DAT+m Compensation.p such 'provisions or this. permit:shall be VAL( H deemed revoked., PViIT ' FU'RNAC'E: FAU G C1 C_ �> LICENSED CONTRACTORS DECLAR-ATfO3�t. -FLOOR _9T U, .' I•herebyaffirm-that.Iam•licensedunder provisions4fChapter HEATER: SUSPENDED " ' `UNIT- 9,(cprpmencmg with"'Section•7000),of Division'3 af`the Busi- WALL Hess and,Professions Code, and my:iid,ense is in full.force anti;_-, effect. �.f f License Num/b�er�! 0�/73�Lic.Class Contractor_(_D 4fA10� �/c Date 9-7 . y. ` I sin exempt.from the-licensing requirements.as I am a, licensed architect or-a registered professional,:engineer • ; :Plan check fee 25%of abOVe. " acting in•my professional'capacity (Section 7051, Bus- mess and Professions Code), PERMIT'ISSUIfVG FfE $ tile.or Iteg::No. DaEe TOTAL-FEEL 'HOME OWNEk-R-UIL.DERDECLARATION. PL'AN'CHECKAPPLICANT �1`hereby, affirm',that ,I ani- exempt from-the Contractoi~'s NAME. License Law, for the following reason (Section 703'1.5 .,Buri-' 0 3, 3' ness'and Pr`ofessions•Code): ADDRESS 3 5+' -t R ElI, as owner.of the peoperty, wilt do the work and the ." CITY TEL. NO 1 t k ? l '(Section '013— .3 , structure.is, not intended or.offered f r sae 7044, Businessland Professions Code) 3 .. OWNER .�j ,' 6' I, as owner of the property„ 'am'exclusively,contracting {_�/2' �f �� 0 0tgT36•506_. with licensed cohtrac''tors to construct• the projects: MAIL � /� � r ADDRESS . J/'O3 /_'i!lu� ��T (Section 7044;Business and.Pro£essioss Code). _ 7� — —`, - ([ Qf$,�Q 9 8 U CONSTRUCTION UtNDING AGENCY C /C� �ple ��.� NO:p2/3s ! l5 CITY TEL' I hereby.affirm that .therd lis'.a construction lending agency Q” CONTRACTOR nn G for. the performance of the work for which--this permit is 0At IAO C ,it /fir q rjV issued(Sec. 3097.,Civ.C.)•_ fi— Lender's Name' ADDRESS Lender's=Address' CITY TEL: NO. I-certify that I have read this application and state that the STATE .` �7 7 LIC: �G >ZO above information incorrect.I agree-to comply`with all County LICENSE NO:, QJ!3� CLASS�c C. B. - ordinances,and State.laws regulating Heating, Ventilating and Air Cotnditioning,'and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE Countyto. enter. uponthe `above-mentioned property for inspP-'ion purposes: Signatur-of Permittee Date