HomeMy Public PortalAbout5703 KAUFFMAN AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C
I*he-feby affirm that I have a' certificate of consent to self CE-818 (2-80) Q p p U C Q T�O N FOR P E R M �T
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab. C.)
Policy No. Company
❑ Certified copy is hereby furnished.
COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspection ( ®R APPLICANT TO FILL IN
ADDRESS department.
+( ADDRESS
Date Applicant I� J (PRINT OR TYPE ONLY`)
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST ,� / }
COMPENSATION INSURANCE n
(This section need not be completed if the work involved ABSORPTFON UNIT, BTU GROSS ST. ' V OO M O
by the permit is for one hundred dollaSs (SI00) oz iess.) DISTRICT NO./ P CESSF BY Q
I certify that in the performan— of the wor!I for which his AIR HANDLING UNIT,CFM \/
permit is issued, I shall n6�ohe
t - plo} any,Person in any mrer v O
soasto beco-A subject W rke/' 1-4--ver,.tior aws. BOILER, BTUj/�� , APPROVALS DATE INSPECTOsSIGNATUREleg
Dat(k _Applic _ __ � � I COMPRESSOR, BTU -(%�`'� f(J O� ROUGH TJ�� � (/� CL
NOTICE TO APPLICANT: If, after making t . Certificate of VENTILATION SYSTEM �! '—
Exemption, you should become subject to the Workers' FINAL �L _
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER
with comply with such provisions or this permit shall be VALIDATION
deemed revoked. FURNACE: FAU�— RA ITY
LICENSED CONTRACTORS DECLARATION r/ FLOOR:- bTU_,O� /O
I hereby affirm that I am licensed under provisions of Chapter I HEATER: SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and
effect.
License Number Lie. Class
Contractor Date �J
I am exempt from the licensing requirements as I am a II
licensed architect or a registered professional engineerIlan check fee 25% of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUONG FFF $ /d
Cic.or Reg.No. Date j T®TAL FFE
HOME OWNER-BUILDER DECLARATION PLAN CH E_K APPLICANT
I hereby affirm that 1 am exempt from- the Contractor'sNAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): � I ADDRES£6JO� �L• -' ACCT.*structure
as owner of the property, will re the work and the CIT TEL. NO. „/ - - 53.75
structure is not intended or offered for sale (Section �L
7044, Business and Professions Code).
❑ OWNER /�o24 N 1 ITEMS
I, as owner of the property, am exclusively contracting _ _
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code). p 1 ADDRESSv�_ � TOTAL ,�_e o �
CONSTRUCTION LENDING AGENCY i CI ���,, TEL.NCHECK .r,2,5
I hereby affirm that there is a construction lending agency
CHANGE''
/fir[{
for the performance of the work for which this permit is CONTRACTOR ■O
issued (Sec. 3097,Civ.C.).
Lender's Name I ADDRESS
Lender's Address CITY TEL. NO. �t�pp�L� � _ 1,� 2/87
I certify that I have read this application and state that the STATE LIC. 48" 1 AM11:39
above information is correct.I agree to comply with all County LL_I_CENSE'NO. CLASS
Ord i .,n es and State laws regir.ating Heating, Ventilating and
Corditionmg, and he ray rulhorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
'ount� to ent.r pr.i th above-mentioned prope for
ins ction pones.
Signature of Permit'ec Date