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Home My Public Portal About5946 KAUFFMAN AVE_Mechanical__ WORKERS' COMPENS, 00' N DE-jLARATION APPLICATION FOR PERMIT hereby affirm that I have a certificate of consent to self insure;dor a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a r ified copy thereof Sec. 3800, Lab. C.) 76A364C 3� CE-818(REV. 10/81) Polity"o.— � pony ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDIN AND SAFETY ❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING T - ADDRESS j �✓7 �L! �-' 9qtion da crime (PRINT OR TYPE ONLY) DateApp licant � �`� �✓°�� r 1 LOCALITY NO. yam/ d Oi NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST � i CERTIFICATE OF EXEMPTION FROM WORKERS' // r/� COMPENSATION INSURANCE CROSS ST. ✓1 Gt A (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY the permit is for one hundred dollars ($100)or less.) I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM ,* 5 permit is issued, I shall not employ any person in any mannerL^ so as to become subject to the Workers'Compensation Laws. IBOILER, BTU APPROVALS DATE 1111 PECTOR'S SIGNAT RE Date Applicant COMPRESSOR, BTU o0 ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER V LID TI with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY— LICENSED RAVITY ,^ Q© LICENSED CONTRACTORS DECLARATION FLOOR BTU (j I hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPENDED UNIT ' (commencing with Section 7000) of Division 3 of the Business WALL � and Professions Cod , and mylicCense is in full force and effect. License Number o 2 1 Lic. Class l a+ U fC' t -7 oil Contractor/1 ��: '. '1� ate�/� r} u ❑ I am exempt under Sec. Plan check feeCIO= B.&P.C. for this reason D f/ PERMIT ISSUING FEE $ / ti ' ? r TOTAL FEE Signature 4 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 , 3 3 A Professions Code): ❑ I, as owner of the property, or my employees with ADDRESS # 0 0 0 0 0 8 wages as their sole compensation,will do the work and CITY TEL. NO.- the structure is not intended or offered for sale(Section ( 0 0 3 Q 5 O 7044, Business and Professions Code). OWNER ❑ I, as owner of the property, am exclusively contracting 0 0 0 30,506 with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and'Professions Code). ADDRESS 22 7.-8 5 CONSTRUCTION LENDING AGENCY CITY 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 (Sec. 3097, Civ. C.). ADDRESS Lender's Name CITY TEL. NO. Lender's Address STATE LIC. I certify that I have read this application and state that the LICENSE'NO. CLASS 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 Signature of Applicant or Agent Date