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HomeMy Public PortalAbout5221 KAUFFMAN AVE_Mechanical__ � •, l .. � p /�, .. �/� ' WOR HERS'COMPENSATION DECLARATION CEA 818.( ),__, Q I(- l �,�.d"a ION' FOR P E R IIVIt T I hereby affirm that I have a certificate of consent to self "' insure,or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING certified copy thereof(See'. 380n T ab.C.). - - Policy No. Coinpany -COUiVTY OFrLOS;`AiUG,EL'ES;° BUILDING-AND SAFETY- s Certified copy'is hereby•furnished. i Certified copy is filed wit i the county br::' in inspection l depgN^�r. FOR APPLICANT TO FILL IN- BUILDING- ) '1 yy � A1' .(PRINT OR TYR.E.ON-LY,). ADDRESS �u� �� ILA _ rw Datee Applican'_ LOCALITY1, CERTIFICATE OF EXEMPTION FIR `.WORKERS'' NO. . TY.PE,OF APPLIANCE OR EQUIPMENT_ .FEE _ _ T COMPENSATION INSURANCE NEAREST`+: t, } (This'section .need not-be''completed if the work lriVolved• - - ABSORPTION UNIT;BTU. CROSS ST. d by the permit is for one hundred dollars ($100) or less.) " DISTRICT NO.'- PRO D r _ I certify, that,in the performance of,the work', wv c(i this °• AIR HANDL'ING.UNIT,CFM, -- :., �___._. „ ,„ �,,, r•, U permit is issued,•I shall not employ any person in any manner O so as'to become subjeci to'the Workers' Compensation Laws. BOILER, BTU f" _ `APPROVALS "DATE `: NSPECTOR'S SI .ATURE - L)- DateApplicant COMPRESSOR, BTU_ /_ n- • 1 .•. l � - .. NOTICE TO APPLICANT: If,'aROUGH (A fter.making this Certificate of VENTILATION SYSTEMz Exemption; you should'become' subject',to' the 'Workers' FINAL' Compensation provisions of the Labor Code, you must-forth-. -' with com 1 with such" rovisions or "this EVAPORATI.VE,COOLER . ., VALIDATION p y p permit shall'•be = +• " ' deemed revoked. FURNACE: FAU. ' -,LICENSED CONTRACTORS DEC.LAR ATION • FLOOR: b I U— - I hereby-affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED' UNIT x _ 9.(commencing with Section'7000)of Division,3:of the Busi-. ^ WALL„- ness and Professions Code, and my license is in full force and - License Number . Lic. Claws ® - Contractor• �� Date I am exempt fiotn'the•licensitig te4uireme'is as Tam a licensed architect or a registered• professional engineer Plan check fee 25%of above. ' - actirig in my•'profes3iorial' capacity (Section.7051,�'Bus- inessand Professions Code). ' _ PERMIT ISSUING FEE, -Lic.or Reg.:No. Date TOTAL FE°E 40 i-IOM'E OWNER-BUILDER bECLAR?ATION PLAN CHECK APPLICANT I hereby. affirm that I am exempts from- the 'Contractor's NAME License Law•for the following reason'(Section,7031,.5, Busi- -ness and Profession's'Code): ., -ADDRESS 1, as owner of the property, will do-the'work and the- r� _ 1 structure is not intended or offered for CITY,sale-(Section' • ` _ ��-1 7044, Business+and Professions Code),., �— 'OWNER A 37,;5,8 A I, as,owner of the property, am exclusively contracting , with',licensed,,contractors to construct the4 1 p roJ ect MAIL 1 1T o'o o ° (get tion'7044,'Business'and Profession's Code). ' . ADDRESS N # CONSTRUCTION LENDING AGENCY - CIT.Y. � `` E_L N_O .2�°,° 2 7 O 6 I hereby affirm that there is a,construction lending agency- 1 x' for the eiformance,of the work for which 'this apermit is CONTRACTOR o`;0 a.2 7 O�w issued(Sec. 3097,Civ.C.). - Lender's Name ADDRESS�a Lender's Address CITY \ a�� ��. TE L.NO I certify that I have read this application and state that the STATE ' 'L'IC'." ^ at -e information is correct.I agree to:comply withAl County LICENSE NO.��� CL-ASS `©- or im Inces'and State lay.- regulating Heating, Vr•. :•ting and Air C. nditioning, and '.eret y auth ize represer cativ s of this., SEE REVERSE FOR EXPLANATORY LANGUAGE , Coy ,ter uq n +a' �ve renti,.L'i��y for insp u I se _ - Signature of I ermittee Date - _ _