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Home My Public Portal About5743 KAUFFMAN AVE_Mechanical__ J'WORKERS' COMPENSATION DECLARATION 11 APPLICATION .F�R PERMIT � a I herelp� km that I have'a certificate of consent to self yore;or certificate of Workers' Compensation Insurance, a.Certified copy thereof (Sec. 3800, Lab. C.) 76A364CHEATING - VENTILATING- AIR CONDITIONING 20-0046 DPW 9/88 Poliry'No: Company COUNTY OF LOS ANGELES BUILDING AND SAFETY �yAartified copy is hereby furnished. C , F] Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion department. ADDRESS A (PRINT OR TYPE ONLY) Date Applicant LOCALITY 11 NO. TYPE OF APPLIANCE OR EQUIPMENT FEE 1 ,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. 15R5 BY the permit is for one hundred dollars ($100) or less.) 1 certify that in the performance of the work for which this AIR HANDLING UNIT, CFM v " permit is issued, I shall not employ any perso in any manner BOILER, BTU. O as t e ome ect to the Work pensation Laws. APPROVALS DATE SPECTOR'S SIGNATURE �> COMPRESSOR, BTU ROUGH 'Z YD_ te. Applicant - NOTIC TO APPLICANT: If, afte i this Certificate of VENTILATION SYSTEM FINAL `e Z_ �� Exemption, you should becom su ' ct 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 deem- ed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU 0 001 I hereby affirm that 1 am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT(commencingWALL.with Section 7000)of Division 3 of the Business • and Professions Code,and my license is in full force and effect. ► License Number Lic. Class o{� 0 O v Contractor Date EI am exempt under Sec. 0 Plan check fee u B.&P.C. for this reason. H PERMIT ISSUING FEE $ ,5' () Z Date: t Signature i�TOTAL FEE 55 OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I her by affirm that I am exempt from the Contractor's License Law or the following reason (Section 7031.5, Business and NAME , Pro ssions Code): �r 1, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and � �{ CITY TEL. NO. the structure is not intended or offered for sale(Section 3307 .5.0 7044, Business and Professions Code). OWNER Z I�� .. I, as owner of the property, am exclusively contracting t� with licensed contractors to construct the project (Sec- MAIL �! TOTAL -_n v � tion 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCYCITY TEL: N Z"1?, CHECK 5.011 I hereby affirm that there is a construction lending agency for CHANGE v01� the performance of the work for which this permit is issued P P CONTRACTOR (Sec. 3097, Civ. C.). ADDRESS Lender's Name 0000-0001 8/31/89 CITY TEL. NO. t 18 54 { N iA �t0:57 Lender's Address 1 !3 I certifythat I have read this application and state that the STATE LIC. pP LICENSE NO. CLASS above information is correct. I agree To comply with all County ordinances and State laws relating to building construction, and hereby auth ize representatives of this ounty to enter upon t entioned property for ins ection urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ign tur o Ap licant or Agent Date f ©5