HomeMy Public PortalAbout5702 KAUFFMAN AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW APPLICATION9,89 FOR PER"R. LI
76A364C ME GREEN
I hereby firm,thattl have a certificate of consent to self insure, f
or a certi;icate of Worker's Compensation Insurance, or a certified HEATING -VENTILATING -NR CONRITIONING
copy theren!(Sec.3800 Lab. C.)
Policy No. Company COUNTY OF LOS_ANGELES DEPT OF,PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished. !!
Certified copy is filed with the county build"g inspect' n FOR APPLICANT TO FILL IN BUILDING
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department. (PRINT OR TYPE ONLY)
Date A licant0 LOCALITY C /'
pP NO. TYPE OF APPLIANCE OR EQUIPMENT FEE C
NEARE
CERTIFICATE OF EXEMP ON FRO ORKERS' CROSS ST. G_.-1 V�
COMPENSATI N INSURA E ABSORPTION UNIT,BTU
(This section need not be completed if the work involved by the ASSESSOR
MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws. (y �pU crl✓ is
COMPRESSOR,BTU d
APPROVALS DATE INSPECTOR'S SIGNATURE '
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLER
provisions,of the Labor Code, you must forthwith comply with such FINAL dJ 11
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR —BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
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License Number Lia Class E"r•_°_s•r�
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CL
mac•'`✓ Date b� �'��� y _1 T L M' a
Contractor i .-•.� U
Plan check fee J +
❑ I am exempt under Sec. / U;AL 77 „ 7I,..,�a:
B.&P.C.for this reason PERMIT ISSUING FEE$ /�G(y ' E1•4 -f7 7-•
fill
Date: TOTAL FEEa %"", UJ
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Signature IL
PLAN CHECK APPLICANT CD
OWNER-BUILDER DECLARATION Z
I hereby affirm that I am exempt from the Contractor's License Law NAME C) , s_j313_jj-_i'U !I
for the following reason (Section 7031:5, Business and Professions l/
Code): ADDRESS .Se t� r•. , Ail
t I a `'
El I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY C)t2V` I EL.NO. I
structure is not intended or offered for sale (Section 7044, V
Business and Professions Code). OWNER wV
❑ I, as owner of,the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS s (�� eJ
tion 7044, Business and Professions Code). 1 ,� l
CONSTRUCTION LENDING AGENCY CITY �!{/� l TEL.NO.a
1 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 /6 w/1 J)-ILI��-
Lender's Name
CITY
Lender's Address STATEV
I certify that I have read this application and state that the above LICENSE NO. - �O of-Z Q C ASSC Zo C—
information is correct. I agree to comply with all County ordinances
and State laws relatin to building construction,and hereby authorize
representa' of t Is County to enter upon the above-mentioned
propert r i sp ct' n p oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNA;Vn OF APPLIC7 OR AUENT ,4 DATE