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HomeMy Public PortalAbout5120 KAUFFMAN AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION b�i1l�I�L�0 CA' H O U w V F O a p E RA T I hereby affirm that I have a certificate of consent to self �( insure, or a certificate of Workers' Compensation Insurance,, HEATING .-*VENTILATING ' AIR CONDITIONINGor a certified copy thereoCE-81 f (Sec. 3800, Lab. C.) C CE 818(REV. 10/81) - Policy No. Company - UL i COUNTY OF-LOS ANGELES BUILDING ARID SAFETY Certified copy is hereby furnished. Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion department. ADDRESS (PRINT OR TYPE ONLY)' Date • r `C �'e Applicant ' US LOCALITY JR NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CE TIF CATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY (This section need not be completed if the work involved by 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 permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE DateApplicant COMPRESSOR, BTU ROUGH ! � d NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL -�1' -� 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 9 SUSPENDED UNIT HEATER: WALL a r `(commencing with Section 7000) of Division 3 of the Business and Professions Code,and my license is in full force and effect. License Number- �`� Lic. Class! D V Contractor / l Date O F V ❑' I am exempt under Sec. w Plan check fee B.&P.C. for this reason PERMIT ISSUING FEE $ /® •�'© Z Date: Signature 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): ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,'will do the work and o 0 0.0 0.8 the structure is not intended or offered for sale(Section CITY TEL. NO. n 7044, Business and Professions Code). " - - � � , ❑ I, as owner of the property• , am exclusively contracting OWNER MAIL r .0 0 ° 7 Q J 0 with licensed contractors to construct the project (Sec ADDRESS S� C�1 tion 7044, Business and Professions Code).' —84 CONSTRUCTION LENDING AGENCY CITY ' "� 'G TEL. NO. � —UZ44 I hereby affirm that there is a construction lending agency.for'. ` the performance of the work for which this permit is issued CONTRACTOR 5�1.� PZ I— D (Sec. 3097, Civ.'C.). Lender's Name ADDRESS 'jV 5• G f 1{"v� . _ / CITY 1 TEL. NOS - GE?`V'I /�� Lender's Address ' STATE LIC. I certify th 'I have read this application and state that the LICENSE NO. Z (/� CLASS. above inf ation is correct. I-agree to.comply with all County ordinanc and State la s relating to building construction, and her authorize re resentatives of this County to.enter - up bove-me to ed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Dae