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Home My Public Portal About5710 KAUFFMAN AVE_Mechanical__ KERS'COMPENSATION DECLARATION CEA 818( 2-80) Q[�p �C�' ° D O(N FOR G�C G3 til �� $where y ,,,firm•-tnat I have a' certificate of consent to self insure, or a certi*icate of Workers'Compensation Insurance,of a certifit;d copy thereof(Sec. 38000,, Lab.C.) [� 1 Policy No..�c22��.ompan y_J�_.�4JM-�-�/l1$.-1—�ti)C ED Certified copy is hereby furnished. COUNTY Or- LOS ANGELES BUILDING �'�®SAf��TY �Certified copy is filed with the county building inspection _ ——— BUILDING J /'1 dtep//��rt ent. �/ A /� �OV� !�'E°6adBOR�fill�T® f�1LL Ofd! ADDRESS 7 ! 0 Date.S/'L� Applicant. Ss S H�e-4.-// �r N<� (PRINT OR TYPE ONLY) // LOCALITY 6e C �J CERTIFICATE OF EXEMPTION FROM WORKERS' I' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE _ ✓] COMPENSATION INSURANCE NEAREST } (This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. a0 by the perrAit is for one hundred Ilars ($100) or less.) DISTRICT NO, PROCE'SF BY (� I certify that in the performance f the work for which this � AIR HANDLING UNIT,CFM_ ��/�/ � permit is issued, 1 shall not emp .y any person in any manner d O so as to become subject to + Workers' Compensation Laws. I BOILER, BTU - 'Y'8yr `/yr APPROVALS DATE I SPE R'S SIGNATURE (� Date Appli ant_ _ COMPRESSOR,BTU— �Ud Q �✓ ✓ ROUGH - W CL N NOTICE TO APPLI ANT: If, after making this Certificate of VENTILATION SYSTEM FINAL tZ Exemption, yo1 should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with com iy with such provisions or this permit shall be deemed revoked. FURNACE: F A U GylITY _ � LICENSED CONTRACTORS DECLARATION FLOOR: BTU-6 66,66, �rz. I hereby affirm that I am licensed under provisions of Chapter 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. I V(J ,GG License Number�Jo�x�-1_ Lic.Class— Contractor(Ek5 AC_-&"t Date ElI am exempt from the licensing requi--.vents as I am a licensed architect or a registered ,rofessional engineer !Plan check fee 25%of above. acting in my professional car dy (Section 7051, Sus- o iness and Professions Code [ �CvNuCT�� "� �V �l/ 4 5 7.9 A Lie.or Reg.No. Date TOTAL. FETE # • ®.o • e $ HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ° 4625 I hereby affirm that I am exempt from- the Contractor's NAME 4 6 2 5= License Law for the following reason ection 7031.5, Busi- ° o • ness and Professions Code): i ADDRESS [, as owner of the property will do the work and the 5.Q 2 "$b structure is not intende or offered for sale (Section CITY TEL. NO. 7044, Business and Prof Bions Code). ir TOWNER I, as owner of the operty, am exclusively contracting e.�!_'� with licensed c tractors to construct the project MAIL (Section 7044, usiness and Professioas Code). ADDRESS CONSTRUCTION LENDING AGENCY CITY TEL.NO. I herebyaffirmthat there is a construction lending agency ¢ for the erformance of the work for which this permit is CONTRACTOR C/ // issued (Sec. 3097,Civ.C.). -" Lender's Name I ADDRESS Lender's Address CITY ,v lr TEL.NOB76/,�` / �ZlAS�9 I certify that I have read this application and state that the STATE © !Q LIC. above information is correct.I agree to comply with all County LICENN SE O^ 1 CLASS ordinances and State laws regulating Heating, Ventilating and Air Conditioning, and hereby authorize representatives of this � SEE'REVERSE FOR EXPL NATORY LANGUAGE County to enter upon the a' we-mentioned property for 17l`�J�� inspect' n pu ses. (G7—c — Signatu a of Permittee Date