HomeMy Public PortalAbout6008 KAUFFMAN AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 2D-0046 DPW 9/89 APPLICATION 0=0R PERMIT
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I hereby affirm that I have a certificate of consent76A364C to self Insure, -L'1 E•'„ G RE E N ,
or a certificate�f,Nj3al�5r'+rCom ensation Insurance, or a certified
rt� P HEATING
-'VENTILATING -AIR CONDITIONING.
copy hereof(Sec.3800 Lab " • - _
X0011C
."COUNTY OFLOS'ANGELES 'DEPTOFPUBLIC WORKS- BUILDING'�ANDSAFET.Y DIV.Certified copy Is hereby furnished:, ,,. Certified.co is filed with the coup Idi insp tion FOR APPLICANT TOLFILL IN• BUILDING f� J
PY ADDRESS
de artment, z, (PRINT OR TYPE ONLY)• �"' � !"�'
Date �' Appkcant " LOCALITY
NO - TYPE OF APPLIANCE OR EQUIPMENT - FEE
CERTIFICATE OF EXEMPTKJFROM RKERS' NEAREST
�•' CROSS ST -
COMPEN ATIO RANCE ABSORPTION UNIT,BTU
This section need not be completed if the work Involved b the ASSESSOR ;.
( ,P y ;J - MAP BOOK - PAGE '',' ]PARCEL
permit Is for one hundred dollars,($100)or less.) AIR HANDLING UNIT,CFM '
Y , v- DISTRICT NO PROCESSED BY ,
I Certrfy:that in the performance of the work for which this permit
is issued,'I shall not employ any person ih'any'man ner so as to BOILER,BTU
become subject to the Workers' Compensation Laws r d�
COMPRESSOR,BTU ''
_- - _ :.,'-" _ - f' APPROVALS . DATE INSPECTOR'S SIGNATURE'
Date Applicant 'VENTILATION SYSTEM a,
NOTICE TO APPLICANT If,'afte( making this Certificate of ROUGH
Exemption;you should become subject to the Workers'Compensation EVAPORATIVE,COOLER
provisions'of;the Labor Code,'you must• c'Ahwith comply with such FINAL
provisions or this permit shall be`deemed revoked. FURNACE: • FAU GRAVITY w
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I'hereby affirm-that'b'am licensed under provisions of Chapter 9 NDED - IT,
HEATER;
(commencing`with Section 7000) of Dryision 3 of the Business and ALL
Professions'Code, and-my licerise•is in full force and effect.
Q O :AC:GT.Q o
License Number oO•� Lia Class �� ( �03 7� .
' 1 ITEMS 5 . . cL
Contracto f Dat'e'' 0
❑ I am exempt•under S c Plan check fee TOTAL 53 - 90 V
B.&P.C.forthis reason PERMIT ISSUING. $ Q � c3"�� O
r,.-' 3::
Date: TOTAL FEE C��E ���, U
-Signature . t _��. - ,a
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT q f7�ft e'qt U)
I hereby affirm that I am exempt from the Contractor's License Law NAME a,: l [V X17-�►. 1hI� 7I.C� Z
for the following.reason (Section 7.031 5, Business and'Professi'ons A1111�c7
Code): 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.: 4 -
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER '
,❑ I,=as owner of the:property, y contiactin ,-� MaQ-e
p p y, am exclusive) g MAIL A17� •;
with licensed contractors to construct the project (Sec- ADDRESS 6Q(� I"\,--
tion
_
tion 7044, Business and Professions_ Code)
CONSTRUCTION LENDING AGENCY CITY —� TEL ��' -
I hereby•afflrm that there is',a construction lending agency for > '•, �; '
the performance of the work for which this permit is issued CONTRACTOR /
(Sec.,3097,Civ. C.). 'tl�l: � G� Poo,
ADDRESS' OI J S- 7e '
Lender's Name �, } �/�y c "
CITY 1-1 /�"' /�'-.�-TEL.NZ-�S Z
Lender's Address STATE c LIC /
I certify that'I have read this application and state that the above LICENSE NO (� Q 7• CLASS (�'�Z'd „
Information is correct. I agree to-comply with all County ordinances _
and State laws relating to building construction,and hereby authorize'
represent of this,County to enter upon the above-mentioned
prop y for in act' uses. SEE REVERSE F_OR EXPLANATORY-LANGUAGE'
.SI R PDCANT O AGENT DATE ' ' _ - - •