HomeMy Public PortalAbout5817 KAUFFMAN AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION O MIT
I,hersby.a#fi•rm thf�t I have a certificate of consent to self
iosdre, or,a certsficate_ofa,Workers' Compensation Insurance, �6A364C HEATING - VENTILATING - AIR CONDITIONING
,,or a•cari'i lied topy,thereot�(Sec. 3800, Lab. C.)
{ CE-818(REV. 10/81)
Policy No. Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY
' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE `
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100)or less.)
AIR HANDLING UNIT, CFM G�
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 become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATESPE S SIGNATU E
L � i��r COMPRESSOR, BTU ROUGH J
Date Applicant _ _
NOTICE TO APPLICANT: If, after making this Certificate of ` VENTILATION SYSTEM (`/} FINAL
Exemption, you should become subject to the Workers' 1
Compensation provisions of the Labor Code; you must forth- EVAPORATIVE COOLER VALIDAT ON
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION r FLOOR BTU Ltir-0 i
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business WALL z 1 1 :12 A
and Professions Code, and my license is in full force and effect. A.
# 0 0 0 0 0 8 O
License Number,401 tLic. Class k;
Contractor—IT �y "17C t !,�' Date L 1 — o O 'I 0 0 40.50 O
F-
❑ I am exempt under Sec. o a 0 4 0,5 0 0 w
Plan check fee
B.&P.C. for this reason PERMIT. ISSUING FEE $ ) 1,.1 .0`8 8
Z
Date: TOTAL FEE
Signature ,
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
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code).
❑ I�L-LI I, as owner of the property, am exclusively contracting OWNER
with licensed contractors to construct the project (Sec- MAIL l'
tion 7044, Business and Professions Code). ADDRESS 1( CU-A ft_ vv+
CONSTRUCTION LENDING AGENCYCITY i TEL.NO.
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR C - ,
(Sec. 3097, Civ. Ci).
4 ADDRESS p
Lender's Name
CITY TEL.NO.
Lender's Address
STATE LIC. L� yt
I certify that I have read this application and state that the LICENSE NO. �Ar CLASS {� iC-Yb' ley
above 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 property for inspection purposes_ SEE REVERSE FOR EXPLANATORY LANGUAGE
l..h� Z.� ✓tom
Signature of Applicant or Agent Date