HomeMy Public PortalAbout5822 KAUFFMAN AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 �'/
76A364C APPLIC' TI&'N FOR PERMIT LIME GREEN,,
I hereby affirm pt kt'I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof )
(Sec.3800 Lab.C.
Policy No. + Company . COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Ced copy is hereby furnished.
Certified copy is filed with the county buildi in ection FOR APPLICANT TO FILL IN BUILDING p �
depa ment. (PRINT OR TYPE ONLY) LOCALITY
ADDRESS O
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST 047
COMPENSATION INSURANCECROSS ST.
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollara($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO, PROCESSED BY
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
become subject to the Workers' Compensation Laws. �`
COMPRESSOR,BTU WVA 6r
APPROVALS DATE INSPECTOR'S SIGNATURE /
Date Applicant VENTILATION SYSTEM
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 7—2—
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU 3 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 Number 2" V� ic.Class
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Contractor Date--6-L ,
ate L - O
F] I am exempt under Sec. Plan Check fee U
B.&P.C.for this reason PERMIT ISSUING FEE _ Q
H
Date: TOTAL FEE
Signature fl
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
Z
I hereby affirm that I am exempt from the Contractor's License Law NAME / Poo. =3`-"'D _
for the following reason (Section 7031.5, Business and Professions :,
Code): ;€_:€ 1_ 3 , '
❑ ADDRESS
I, as owner of the property, or my employees with wages ]
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, t,}E�1„= {w
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS _,#€_z—°,;;:l y _. f
tion 7044, Business and Professions Code). —� :-x - r i
CONSTRUCTION LENDING AGENCY CITY TEL.NO. .F`
I hereby affirm that there is a construction lending agency for CONTRACTOR
,
the performance of the work for which this permit Is issued CO
(Sec.3097,Civ. C.).
ADDRESS.' �—
Lender's Name
CITY TEL.NO.
Lender's Address STATE � .�J' LIC. 1
I certify that I have read this application and state that the above LICENSE NO. LI p CLASS �G ”
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives is County to enter up n the above-mentioned
property fo eq' n p os SEE REVERSE FOR EXPLANATORY LANGUAGE '
SIGNATURE OFAPPLICANT OR AGENT PIATE