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Home My Public Portal About6022-6028 KAUFFMAN AVE_Mechanical__ WORKERS',COMPENSATION DECLARATION APPLICATION FOR PERMIT i&,,l hereby'affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compens"ation'Insvrance, HEATING - VENTILATING - AIR CONDITIONING CE-818 or a certified copy thereof (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. (This section need not be completed if the work involved by ABSORPTION UNIT; BTU DISTRICT NO. PROCESSE BY i the permit is for one hundred dollars ($1 00)or less.) AIR HANDLING UNIT, CFM I certify that in the performance of the work for which this S� n 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 DATE INSP.CTOR'S SIGNATURE App ic � aaiv// , COMPRESSOR, BTU ROUGH ��ibbb ��-/��:L//-� - 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 VALIDATI N with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU v 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 WALL and Professions Code,and my license is in full force and effect. 00 • License Numb//� �/Z Lic.,Class `` ?'� , ;2 8 6 5 7 A lJ Con�.rn!!mpt dP /�+� Daft _ _ #.o o 0 o o 8 O_ ❑ under Sec. o - 44.50 9" Plan check fee 0. B.&P.C. for this reason' PERMIT ISSUING FEE $ a - a 4.4,5 0 x U Date: TOTAL FEE 2 2 4=8 7 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 CITY TEL. NO. the structure is not intended or offered for sale(Section 7044, Business and Professions Code). OWNER ❑ I, as owner of the property, am exclusively contracting MAIL with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY TEL. NO. I hereby affirm that there is a construction lending agency for pool performance of the work,for which this permit is issued CONTRACTO ` G (Sec. 3097, Civ. C.). ADDRESS Lender's Name CIT (7 TEL Lender's Address I certify that'I have read this application and state that the LICENSE 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 WORKERS;COMPENSATION DECLARATION APPLICATION FOR PERMIT "�'F hereby affirm that,I have`a certificate of consent to self f insure, or a certificate of Workers' Compensation Inst rance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C 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 �y tion department. (PRINT OR TYPE ONLY) ADDRESS Ci Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (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.) AIR HANDLING UNIT, CFM I certify that in The performance of the work for which This permit is issued, I shall not employ any person in any manner BOILER, BTU so as to become subject to the Workers'Compensation Laws. e' APPROVALS DATE "CTOR'S SIGNATURE COMPRESSOR, BTU /� ROUGH ate Appliconnj� vv 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 VALIDATION. with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU R VIT / /} • LICENSED CONTRACTORS DECLARATION FLOOR BTU . ( !O d 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 WALL and Professions Code,and my license is in full force and effect. �T��, IL � !tILJ Ol f O License Nu rr „ 2 / Lic. Class G'� , U Cont - �- Date— Z 2, 8656A 0 ❑ I am exempt unde Sec. tu Plan check fee a � a000ag B.&P.C. for this reason PERMIT ISSUING FEE $ Date: TOTAL FEE ' - o44,50 � ' Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT o o o,41L 5 0 c5.� I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and NAME 1224 -87 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). OWNER✓�� ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY CITY TEL. NO. I hereby affirm that there is a construction lending agency for pool performance of the work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C.). ADDRESS Lender's Name CITY TEL. O Lender's Address , STATE LIC. �r7 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 t e above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date - - W. •+<rkPKERS`COMPENJATION DECLARATION APPLICATION FOR PERMIT / I hereby affirm that I have a certificate of oDn�t to self insure, or a certificate of Workers' Compensation Insutl'hnce, 76A364c HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (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 O tion department. (PRINT OR TYPE ONLY) ADDRESS Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCECROSS SSC' - �GF?y{�. (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.) //Jy AIR HANDLING UNIT, CFM i V 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 Worker's'Compensation Laws. BOILER, BTU /Q APPROVALS DATE s CTOR'S SIGNATURE DGt � ApplicdlZt�"��C��"�t '� t� COMPRESSOR, BTU 0 ROUGH j Y_ 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 VALIDATI N with comply with such provisions or this permit shall be deemed revoked. % FURNACE: FAUBAVIT f'd LICENSED CONTRACTORS DECLARATION ` FLOOR BTU 'A (1 I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000) of Division 3 of the Business HEATER: WALL ' and Professions Code, and mylicenseis in full force and effect. ,J,L ��.�- , 0 License Numb ei c' / Lic. CIassG ( T(r L ("� 2 8 6 5, 9 A 11 Contrc q� Datw� oil. # 0 0,o 0,0 8 t•- ❑ I am exempt under Sec. 1 ° - 44,50 LU Plan check fee CL v' B.&P.C. for this reason PERMIT ISSUING FEE $ U ° o o 4 Ll5 0 Date: 12,24-87 Signature TOTAL FEE 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). OWNER ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL Tion 7044, Business and Professions Code). ADDRESS 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 CONTRACTO , (Sec. 3097, Civ. C..). ADDRESS 4/G! Lender's Name CITY" TEL. Nva It�. Lender's Address vc STATE LIC. / 7 1 certify that I have read.this application and state that the LICENSE NO.Q 3 Z.1P 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 t e Bove-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SI u e of Applicant or Agent Date j&• i'WORkERS'COMPENSATION DECLARATION her3'by . APPLICATION FOR PERMIT ^.J affirm that I have a certificate of consent to self insure; or a certificate of Workers' Compensation lnsorance, 76A364C HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (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. ADDRESS (PRINT OR TYPE ONLY) Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE C� CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (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.) AIR HANDLING UNIT, CFM e \ `U I certify that in the performancof the work for which this V permit is issued, I shall not employ any person in any manner so as to become sub'ect to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE IN OR'S SIGNATURE /U ApplicQ�l COMPRESSOR, BTU- �� 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 VALIDATI N with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU G AVITY 10 /1 LICENSED CONTRACTORS DECLARATION FLOOR BTU . U 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 WALL and Professions Code,and my license is in full force and effect. License NumLic. Class r Dat/�—2- y- ❑ V I am exempt u er Sec. � Plan check fee B.&P.C. for this reason z 8 6 S 8 A Date: PERMIT ISSUING FEE $ Signature TOTAL FEE # aaaoag OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT o o 4 4.50 I hereby affirm that I am exempt from the Contractor's License ► o 0 0 4 4 5 0 c=i Law for the following reason (Section 7031.5, Business and NAME Professions Code): ( 224-87 El1, 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). OWNER ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS 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 CONTRACT 0 (Sec. 3097, Civ. C.). ADDRESS Lender's Name Lender's Address CITY >J/l__,TEL. STATE �(� CLASS I certify that I have read this application and state that the LICENSE NO.�� (jZCLASS :r 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 th above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date