HomeMy Public PortalAbout5106 KAUFFMAN AVE_Mechanical__ u
WORKERS'COMPENSATION DECLARATION n.�Pn CATPOH FOR
PERM67 "
herE.Vy�affifm that I have a certificate of consent to self W I-L. IJ�J L2 (Jv�J
insure, or a certificate of Workers' Compensation Insurance, _ _HEAUNG - VENT1LATING - AIR .'CONDITIONING
or,a certified copy thereof (Sec. 3800;'Lab. C.) 76A364C.
CE-818(REV. 10/81) -
Policy No•p-T 3 Pany "Gf-)I den .Eds1P
Cer4ified"copy is.hereby.furnished.. COUNTY OF LOS ANGELESBUILDING AND SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO-FILL IN- BUILDING
tion'de artment. ADDRESS 5106 Kauffman
-, P � (PRINT OR TYPE ONLY) •
Date7/ % A RS LOCALITY . Tem le City.
T� $ pPlicanr NO. TYPE OF APPLIANCE OR EQUIPMENT .. FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION'1NSURANCE CROSS_ST. Lower AZ
ABSORPTION UNIT, BTU - DISTRICT NO. _PROCESSED BY
(This sectiod need not be,completed if the work involved by. •
the permit is For one hundred dollars($100)or less.)
AIR HANDLING UNIT,CFM
I-certify thatinthe performance"of the work for which this
permit is issued,I shall not employ-any person in any manner
BOILER, BTU
' sous to become subject to the Workers'Compensation-Laws. - APPROVALS DATE I OR'S SIGNATURE
Date -Applicdnf COMPRESSOR,BTU ROUGH 4 r) 1
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, youmust forth- EVAPORATIVE COOLER VALIDATION ,
with comply witR"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' �pil
'(commencing with Section 7000) of Division 3-of the Business WALL ! // (old
and Professions Code, and my license is",in full force and effect:
License Number 4 o n�R 9 Lic:Class` R LOJ
ContractorPVRAMTD •RTTTT lg(Rc ('/T 7./S2 R O
I am exempt under Sec. d
Plan check fee H
B.&P.C. for this reason" Z
PERMIT ISSUING.FEE $ �Jv_
Date: x.0:1 9.2 A
Signature TOTAL FEE' #L°',° °'.°'° 8.
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the ContractoYs License D ! ® ° 0.5Law-for the follow,irig reason (Section 7031 5, Business and NAME
PYRAMID: BUILDERS _
Professions Code): -.210.5 0
❑ 7, as ownei of the ro ert or m em to ees_with ADDRESS
wages as their sole compensation,will do he work an •
d o 1 4 1-88
the structure'is not intended or-offered for sale(Section CITY Covi 'TEL. NO.
na 967. 1342 :
7044, Business and Professions Code).
• OWNER Mr. _ & Mrs . Herb. Navarette
❑ I, as;owner of the property, am exclusively contracting •: _
with licensed contractors,to-construct the project (Sec- MAIL' -
tion 7044, Business.and Professions Code). ADDRESS.'.5,106 'Kauffman
CONSTRUCTION.LENDING AGENCY' CITY TEL. NO.
I hereby affirm that there:iso construction lending•agency for ' Temple Cit 2 8-6: .61398
the performance of the work for which this.permit Js issued CONTRACTOR P. ramid
D
.(Sec. 3097, civ: C:). '. Budde-rs
ADDRESS
Lender's Name
Lender's Address
CITY Covina TEL NO.967. 1342-11
•
STATE LIC.
I certify that'I have read this application and state that the . 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 ,
6.117./8 8
-Signature of Applicant or Agent Date "''