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HomeMy Public PortalAbout5729 KAUFFMAN AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9,89 I'hereby affirm that I have a certificate of consent to self insure, APPLICATION FOR PERMIT 76A364C LI M E GREEN':. or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec. 3800 Lab. C.) Ll 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 building inspection FOR APPLICANT TO FILL IN ADDRE S. 9 department. (PRINT OR TYPE ONLY) LOCALITY Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS ST. COMPENSATION INSURANCE ABSORPTION UNIT,BTU p This,section need not be completed if the work involved b the ASSESSOR D p� Ea p P C ) ). Y AIR HANDLING UNIT;CFM DISTRICT BQNOK !J PROCESSED BY � PARC E," is for one hundred dollars $100 or less. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU `® p become subject to the Workers'Compensation Laws. / COMPRESSOR,BTU � o (� Date Applica ',/L•C,� VENTILATION SYSTEM APPROVALS DATE INSPECTOR'S SIGNATURE NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption, you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL 6—o- provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU dr.a 4 VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000) of Division 3 of the Business and HEATER: WALL Professions Code, and my license is in full force and effect. License NumberLic.Class — oma-- o CoA4 Date w _ �e.e.pt ec. Plan Check fee B.&P.C.for this reason PERMIT ISSUING FEE$ L�Q U Date: TOTAL FEE LU Signature U) OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT z I hereby affirm that I am exempt from the Contractor's License Law NAME for the following reason (Section 7031.5, Business and Professions 0�C�7— `� ilvJ✓( . Code): ADDRESSAf_ ca ❑ 1, as owner of the property, or my-employees with wages � �� y=_. _ as their sole compensation, will do the work and the CITY �sTEL.N . L_ 12 2L. structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER ❑ I, as owner of the property, am exclusively contracting MAIL TO!SiiL 122 - 25 with licensed contractors to construct the project (Sec- ADDRESS ` CHECK _ _, tion 7044; Business and Professions Code). CITY �_� T .I "./ iii s CONSTRUCTION LENDING AGENCY gi - LI I hereby affirm that there is a construction lending agency for CONTRACTOR C. +All�� , ,, sht the performance of the work for which this permit Is issued S E �G/ (Sec.3097,Civ.C.). ADDRESS Lender's Name r a T J !__4x11 �lUa' _ri;-;, CITY. TEL.NO. Am`0:r Lender's Address STATE ����� LIC. I certify that I have read this application and state that She above LICENSE NO. CLASS 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 upon the above-mentioned proper i purposes. /© SEE REVERSE FOR EXPLANATORY LANGUAGE s Sl E O N R AGENT DATE