HomeMy Public PortalAbout5216 KAUFFMAN AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 APPLICATION' FOR PERMIT LIME . GREEN
76A364C
I hereby affirm that I have a certificate of consent to self Insure,-
or acertificate of Worker's,Compensation Insurance, or a certified i HEATING'-VENTILATING.-AIR CONDITIONING
'copy thereof(Sec.3800 Lab.C)
Policy No Company :COUNTY OF LOS ANGELES DEPT OF PU,BLIC'WORKS -_BUILDING AND SAFETY DIV.
I
❑ Certified copy is hereby,furnished.
❑ Certified copy is'flled with the county building Inspection FOR APPLICANT TO,FILL IN BUILDING
department. , - (PRINT OR TYPE ONLY) ADDRESS KA 0`- 77 4-1/"
-
DatLOCALITYe Applicant NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'- NEAREST, '
COMPENSATION INSURANCE -ACROSS ST'
. BSORPTION UNIT,BTU- ASSESSOR - • '• '
"(This sectlon need not be completed if the work involved by the MAP BOOK PAGE PARCEL
t- permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM PRocEssEoev
h, DISTRICT NO
I certify-that in the;performance of'the work for which this permit
IS,Issued, I shall not employ an person In an man er so as to
P Y. Y P Y BOILER,BTU h.f CJi
become subject to the Workers' Compens tion 4ws.• • _ - , (/U j��I;Z,l�tili�;•.'
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3
- APPROVALS � DATE INSPECTORS SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO'•APPL'IC'ANT: If, after ma a g this Certl cate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER.
pr6 Bions of the Labor Code,.you'must forthwith comply with such FINAL
provisions or-this permit shall'.be deemed revoked. FURNACE. FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR- BTU VALIDATION.
Thereby affirm that I am'licensed under provisions of Chapter 9 SUSPENDED UNIT •-
• (commencing with Section 7000) of Division 3 of the Business:and HEATER:
Professions Code, and my license is in full force and effect.
License Number ��/®� Lic.Class
qhs _ 9't. z -p
Contractor: �' /7 R Sy� Date � ��
El .1 check fee = ;
I am exempt under Sec.• O
K-.
B.&P.C.for this reason PERMIT.ISSUING FEE L-
Date: TOTAL.FEE U
/ W
i,
0-
Signature
PLAN CHECK APPLICANT
OW NER-BUILDER_DECLARATION
hhereby affirm'that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031:5, Business ands Professions
Code)::- -
❑ I, as owner of the property, or my'employees with wages
as their sole compensation;will do the,work 'and the ' 'CITYTEL NO °' - a• :•.j '
structure is not intended or offered for sale (Section 7044, _ s Li 1M' '
Business and;Professions Code)- OWNER
"I, as owner`of the property;,am exclusively.contracting
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with licensed contractors to'construct-the project:•(Sec- ADDRESS $2ly�)�f`
tion 7044, Business and Professions Code).- 4 cy Ff
/ TEL.NO. r,�ttif,Jz ,;til ,
--CONSTRUCTIONCITY LENDING AGENCY G " r
I hereby affirm that there is a construction lending agency-for CONTRACTOR
the-performance of•the work- for which this permit Is ,issued ,
(Sec 3097, Civ. C.)
- ADDRESS
Lender's Name ^, -
5 t Y A (, /_Hi
_? CITY r— TEL'NO �O /
'4
Lender's Address STATELIC'! ;r,' - -•-
I certify that I have read this application and state that the'above LICENSE NO. Q CLASS- if
Information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize "-
lepresen tives of this)bounty to enter upon the above-mentioned
oropert or pact, purposes.
SEE'REVERSE FOR EXPLANATORY LANGUAGE ,
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jor-�l ?G
N URE O ICA OR - DATE - „ , •-
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