HomeMy Public PortalAbout5734 KAUFFMAN AVE_Mechanical__ RS'COMPF.N$ATION DECLARATION 76A364C
J • o o •
hr ittarm that I have a' certificate of consent.to pelf CE-818 (2-80} A fl"no P LLQ C A T�O II�l FOR R UVU 11 F E
irf}Nre, or a ce%lificate of Workers'Compensation Insurance,or I HEATING-VENTILATING-AIR CONDoTOONO`MG
a certified copy.,hereof(Sec. 3800,Lab.C.) 1`
Policy No. Cnmoany
Certified copy is hereby furnished. COUNTY DE LOS ANGELES BUILDING ARID SAFETY
Certified copy is filed with the county building ADOREss inspection BUILDING
FOR APPLICANT TO FILL IN �� �
department. �/ /� �CY.�G��li.✓12f[./ t/
Date Applicant I (PRINT OR TYPE ONLY)
LOCALITY 0
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST }
CROSS lL
(This section need not be completed if the work involved ABSORPTION UNIT, BTU 0
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSED BY 0
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 U 0
so as to become subject to the Workers' Compensation Laws. BOILER, BTU ~
/l APPROVALS DATE MP TOR'S SIGNA REC167 IU
Dat•=a _P pticant _ !- COMPRESSOR,BTU !/ / o ROUGH — Cn
NOTICE TO APPLICANT: If, after making this Certificate ofVENTILATION SYSTEM Z
Exemption, you should become subject to the Workers' FINAL
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shail be
deemed revoked. FURNACE: FAU QRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTUs l�P_4— / O
I hereby affirm that I am licensed under provisions of Chapter ; HEATER: SUSPENDED J 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 Numbe-_ 3.!— /.G±c.Class
i
Contra .or _ Date_ 9
I am exempt from the licensing requirements as I am a �
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus- PERMIT ISSUING FEEiness and Professions Code)..
Lic,or Reg.No. Date I TONAL EEE (�
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from- the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS f,
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section i CITY �
TEL. NO. - LF_ �cyi(j
7044, Business and Professions Code).
l OWNER
❑ 1, as owner of the property, am exclusively contracting I »
with licensed contractors Pr construct the project MAIL ~.!?F'�;% `'L�.'�_ / =*� 5C]
(Section 7044, Business and Professions Code). i ADDRESS - -' '"'�"`P � »'W'`'�
J FV =`
CITY - �} TEL. N ` ..i
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency CONTRACTOR `r� -"'"�'=� Fcc :•� ❑ ;8!
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.). -
Lender's Name I ADDRESS _
Lender's Address —
C T ,
I certify that I have read this application and state that the ti� Y E L.N
TATE LIC.
above information is correct.I agree to comply with all County LLICENSE NO �1� CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above-mentioned property for
inS ectio , r n ..
�ignamre of Permittee Date