HomeMy Public PortalAbout5121 KAUFFMAN AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION G5 PP �CATPON FOR PERNT
I hereby affirm that,F:have a certificate of consent to_self - l!— L� Il lIV Ili If" j1�w�J '
insu4A,'ar a certificate of Workers' Compensation Insurance, 7ease4c HEATING VENTILATING � AIR CONDITIONING
or a certified'copy thereof (Sec.3800; Lab. C.)
�Qp ' G rill 20-0046 DPW 9/88
Polic�j No. 0 r4'j an y -
❑' Certified copy is hereby furnished. COUNTY- OF LOS ANGELES BUILDING AND SAFETY
' Certified copy is filed with the county b ild'ing inspec= O F BUILDING
FOR APPLICANT OR YP T ILL lid
tibn'department '' - (PRINT OR TYPE'ONLY) - - 'ADDRESS
Date -Applicant LOCALITY 1
NO, TYPE OF APPLIANCE OR EQUIPMENT FEE L
CERTIFICATE OF.EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCEC ROSS ST.
(This section need.not be completed if the work involved by ABSORPTION UNIT,'BTU DISTRICT NO. (ROZXSSED ev
the permit is for one hundred:dollars ($100) or(ess.) . ., LLr
I certify•that in the performance of the work for which this AIR HANDLING UNIT, CFM
permit is,issued, I shall not employ any person in any manner'.
so as to become,subject to the BOILER, BTU Workers' COmpensa}IOn LAWS. APPROVALS DATE INSPECTOR'S SIGNATURE
..Date' Appl icant_
/• COMPRESSOR, BTU «0 ',0 0 ROUGH
>.
NOTICE:TO APPLICANT: If, after making this Certificate ofVENTILATION SYSTEM FINAL
Ex6mptibh, you should become subject to the Workers' i,
Compensation provisions of the Labor ON
Code, you must forth- EVAPORATIVE.000LER VALIDAT '
with comply with such-provisions or this permit shall be deem=
ed revoked ` FURNACE: FAU��A-VI�,Y h
LICENSED CONTRACTORS DECLARATION FLOOR and° 1B8FFl1LLSS (J
I hereby affirm that I am licensed under.provisions of Chapter 9HEATER:- - SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of'the Business WALL
and Professions Code,and my license is in.full force and effect.
/ Dv C-T, v rl_e_T
License Number �+����� Lic. Class Q
U.
'.r Contractor ate
❑.,
O
I am exempt under Sec.-
Plan check fee
B.&P C'fdr thii1reascin. ` a;
Date: PERMIT ISSUING'FEE .$ ` Z
TOTAL'FEE —
Signature'
OWNER-BUILDER DECLARATION PIAN CHECK.A?PLICANT, _
I hereby affirm thatTam exempt from the Contractor's License '
Law for the following reason (Section 7031.5, Business and NAME` D
Professions Code): _
ADDRESS
❑ I, as owner of-the property, or my employees with -C.j,g
wages as their sole compensation,will do the work and CITY - TEL. NO.
-, ;r
the structure is not intended or=offered for sale(Section ' r t 50�•,t.
7044, Business and Professions Code)._
I, as ownerof the property, am exclusively contracting OWNER L M A-P 1--`e 6,L/ I TEM
with licensed contractors to construct the project (Sec- MAIL ] �[ '^ �.:. 5
tion 7044, Business and Professions Code). ADDRESS �/ V } 'I -t'J1� 4�i'L� e I I �n(, _ •_g�5 ® —g
Lt
CONSTRUCTION LENDING'AGENCY '.
CITY 7le^v, r TECNO. CHECK'
53.25
I hereby affirm that there is a construction'lending agency for
the performance of:the work for.which this permit is issued CONTRACTOR f r D ' �IriNG1 "-.00
(Sec. 3097, Civ. C.).
' ADDRESS
Lender's Name f"- i
CITY TEL. NO. �� rl —[€[IIS 1 :kti ...Lr�
Lender's Address STATE LIC. r � '!S A
I certify that I have read this application and state that the LICENSE NO. CLASS
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
upo the abov -Zentioned property for inspection purposes.
�� SEE REVERSE FOR EXPLANATORY LANGUAGE '
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Signature of Applicant or Agent Date "
es