Loading...
HomeMy Public PortalAbout5715 KAUFFMAN AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION I hereby affirm that 'I have a certificate of consent to self APPLICATION FOR PERMIT i4ure, or•a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified /drop thereof Sec. 3800 L C. p76 64y ❑ C Policy N Company Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy ' filed with.the county buil ' g inspec- FOR APPLICANT TO FILL IN BUILDING tion de rtm 1. ADDRESS E/, (PRINT OR TYPE ONLY) Date— Applicant (I LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS'. NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO, PRICES Br the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. BOILER, BTU Y APPROVALS DATE INSPECTOR'S SIG TURE Date Applicant UQ COMPRESSOR, BTU �u d 4600 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 VAI IDA ION with comply with such provisions or this permit shall be deem- ed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED dC UNIT— (commencing with Section 7000)of Division 3 of the Business WALL. and Professions Code,and my license is in full force and effect. License Number 2-7 ' '8-6Lic. Class , d / O Contracto * � make#ag _k ed sAg U 0 ❑ - I am exempt under Sec. I.- Plan check fee u W B.&P.C. for this reason. / H Date: PERMIT ISSUING FEE $ Z Signature TOTAL 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 , Professions Code): I, as owner of the property, or my employees with ADDRESS ACCT-T wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section CITY TEL. NO. 37307 30.50 7044, Business and Professions Code). F-1 1, D 1 ITEMS t�7 I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAILy� TOTAL � !j�l tion 7044, Business and Professions Code). ADDRESS 15 �F:l.d.i• � CONSTRUCTION LENDING AGENCY CITY Tnf �� 9�4 TEL. NO. ��+ {r��P CHECK 30.50 1 hereby affirm that there is a construction lending agency for .10the performance of the work for which this permit is issued CONTRACTOR ��� ��� , CHANGE (Sec. 3097, Civ. C.). ADDRESS Lender's Name c� 11,1000--0001 10/31/89 CITY t' TEL. NO.�S /�,k Lender's Address C� 470 1 AM 8:2 1 certifythat I have read this application and state that the STATE v LIC. PP LICENSE NO. Q D CLASS above information is correct. I agree to comply with all County — ord' nces and STOT laws relating to building construction, d ereb autho a representatives of this County to enter po thea v - tinned property for inspecti n pu poses. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Appli ant or Agent Date ©s