HomeMy Public PortalAbout6027 KAUFFMAN AVE_Mechanical__ WORKER'S COMPENSATION
ate of consent DECLARATION 76A346DPW9/89 APPLICATION FOR PERMIT LIME GREEN.
76A364C
I hereby affirm that I.have-a certificate of consent tq 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.
ElCertified copy is hereby furnished. BUILDING r
'!
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRESS 66z-, �° v Mj
department. (PRINT OR TYPE ONLY)
LOCALITY
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST 00
^��/ ^
COMPENSATION INSURANCE ABSORPTION UNIT,BTU CROSS ASSESSOR �/ �jl
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws. 6e
COMPRESSOR,BTU O
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such I FINAL
provisions or this permit shall be deemed revoked. /J FURNACE: FAU G ODL7 1
LICENSED CONTRACTORS DECLARATION p" FLOOR BTU L�/000 �p D VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
- �GGGC.Civi /�
License Number Lic.Class w4 ��
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Contractor Date V
❑ Plan check fee HAI! y
I am exempt under Sec. Mei ?-PERMIT ISSUING FEE$ O
B.&P.C.for this reason 0
's Y'O(afs� V
Date: TOTAL FEE 10
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Signature __ d r ^* (-
PLAN CHECK APPLICANT 3"f` I
CO
OWNER-BUILDER DECLARATION Ls t F s r I -_ Z_
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions •t;�� ;
Bode): ADDRESS
4 I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO. 'sf ;`.'� l ry
structure is not intended or offered for sale (Section 7044, ---
Business and Professions Code). OWNER �C /V 7- 42.
? r AM -
I, as owner of the property, am exclusively contracting MAIL /,/�
with licensed contractors to construct the project (Sec- ADDRESS Z �'PIVOW
tion 7044, Business and Professions Code). i ^^
CONSTRUCTION LENDING AGENCY CITY �7�///,/ TEL.NO. Z �t
I hereby affirm that there is a construction lending agency for CONTRACTOR ,
the performance of the work for which this permit Is issued
(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 above LICENSE NO. CLASS I
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatiVs of this County to enter uppn the above-mentioned
prop fo Inspect ry�rpgs SEE REVERSE FOR EXPLANATORY LANGUAGE
U ®[ _ 7 99v
SIGNATURE OF APPLICANT 08 AGENT TE