HomeMy Public PortalAbout5709 KAUFFMAN AVE_Mechanical__ WORKERS', I have a TION.cate of
�APPuCATION FOR PERMIT
I hereby affirm that I have a certificate of i;onse;t tb self, - '
insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
CE-81
or a certified copy thereof (Sec. 3800, Lab. C.) C
CE 818(REV. 10/81)
Policy No. Company Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tm
(PRINT OR TYPE ONLY) ADDRESS
iq,D deBorunent'
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. (if
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars ($100)or less.) 5��
AIR HANDLING UNIT, CFM
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 become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant COMPRESSOR, BTU /V� ROUGH
NOTICE TO APPLICANT: If, after making'this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAUGRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: 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.
O
License Number Lic. Class ,
Contractor Date O
a
❑ I am exempt under Sec.
Plan check fee �
B.&P.C. for this reason' O
Date: PERMIT ISSUING FEE $
TOTAL
OTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ` ►
Law for the following reason (Section 7031.5, Business and NAME �) :�� ���tlS/
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS �L ��G ��� 0,1 8 3 2 A
wages as their sole compensation, will do the work and
the structure is not intended or offered for sale(Section CITY C L` ® ,¢TEL. NO. #,o0 0'0 0 8
7044, Business and Professions Code).
OWNER (}- 20 - 30.50
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAILADDRESS / {/ /� �70`-/ a oto 305 Q U
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY 7 TEL.NO. 0 6,07' 84-
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name `--
CITY � `�/O� TEL..NO.
Lender's Address �v
I certifythat I have read this application and state that the STATE LIC. (�C
pp LICENSE NO. CLASS �� ` JZVE
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
u n a above-mennj/oneed propertyyfgspec Lon urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date