HomeMy Public PortalAbout6014 KAUFFMAN AVE_Mechanical__ DECLARAT
2G-00
WORKER'S I COMPENSATION
ate of consent to 76A346DPW 9/89 APPLICATION FOR PERMITLIME GREEN,
" 76A364C
I hereby affirm that I have a certificate of consent to self insure,
or a csrtificate'of worker's Compensation Insurance, or a certified HEATING -VENTILATING -AIR CONDITIONING
copy thereof(/S;e�c.. 3800 Lab. C.) �J
Policy N6.16`�" Company S��TLr U � COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
Certified copy is filed with the co)nybuilding inspection FOR APPLICANT TO FILL IN ADDRESSdeppartment. (PRINT OR TYPE ONLY)Date % • Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM RKERS' NEAREST
CROSS ST.
COMPENSATION INSURANC 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 dollars($100)or less.) AIR HANDLING UNIT,CFM
- DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU C/
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU 00 L
444
APPROVALS DATE INSPE TOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH La
Exemption,you should become subject to the Workers'Compensation
EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU 10ll o VALIDATION
I hereby affirm that I am licensed under provisions of Chapter.9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect. f
License Number 2 Z ic.Class C'-a-v
Contractor I� Date , 0
❑ I am exempt er Sec. Plan check fee 1=
B.&P.C.for this reason PERMIT ISSUING FEE$ (� O
Date: =' 7 1��. 0 W
TOTAL FEE p�� o�.
1 1TEMES a
Signature
OWNER-BUI D DECLARATION PLAN CHECK APPLICANT .,,-_ ,,. 2 25 CO
................. .
TOTAL 1 -
I hereby affirm that I am exe from the Contractor's License Law NAME -• ,c
12r�
for the following reason (Section 7031.5, Business and Professions tv.�iL�.�� +e+-•=
Code): ADDRESS f,.•Fti 1{7E a U0
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,
Business and Professions Code). WNER W1L,C '0000-0001 ;jAt/�,�.i
❑ I, as owner of the property, am exclusively contracting MAIL ��YY �. 83{ 9 1 AM11:57
with licensed contractors to construct the project (Sec- ADDRESS b Jdfl� ;!
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY LCONLTRA16OR
L,+ L°�! TEL.NO.
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued
(Sec.3097,Civ.C.). �Q��p /�,�`
ADDRESSlog6 -B "`1.0'0 (q,0� MW `
Lender's Name wJ
CITYlive ,rTEL.N 330— _
ZK
Lender's Address STATE ~�l tq� LIC. a4 t,
I certify that I have read this application and state that the above LICENSE NO. 6./_3'Z Z CLASS (2 Z� '
information is correct. I agree to comply with all County ordinances
and State laws relating to building c nstruction,and hereby authorize
repres tatives of this County t enter upon the above-mentioned
pro e y for inspection purp es. SEE REVERSE FOR EXPLANATORY LANGUAGE
3W- g � ,
't(GfiATURE 0F APPJd NT OR AGENT DATE