HomeMy Public PortalAbout6031 KAUFFMAN AVE_Mechanical__ a R KERS'COMPENSATION DECLARATION CEA 818C Vis.") (2-80) (A1!I-" IF UC A T�O N FOR P E R M T
T hereU affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or HF_A) MG_V Ey 7ILA�1 0NG-AIR CONDITIONING
a certified copy thereof(Sec. 3800, Lab.C.)
Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection �` — +
department.
FOR APPLICANT TO FILL IN BUILDING
Date Applicant (PRINT OR TYPE ONLY) ADDRESS ' /
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST
I CROSS ST. 7 -���� d
(This section need not be completed if the work involved I ABSORPTION UNIT, BTU 0
by the permit is for one hundred dollars ($100) or less.) ' DISTRICT No. PROCESS D BY (�
I certify that in the performance of the work for which this i AIR HANDLING UNIT,CFM /; (/
permit is issued, I shall not employ any person in any manner Vii 0
so as to� �7 Abeecoome subject to the Workers' Compensation Laws. t� BOILER,BTUT
Date APPROVALS DAT INSPE OR'S SIGNAT RE W
pplicant c+' �/� COMPRESSOR,BTU `f C/ a p.
ROUGH Z
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM
Exemption, you should become subject to the Workers' FINAL
Compensation provisions of the Labor Code, you must forth- I' EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAUGRAVITm
LICENSED CONTRACTORS DECLARATION �� / FLOOR: BTU-;7 4_OC_� O
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with,Section 7000)of Division.3 of the Busi- i WALL
ness and.Professions Code, and my license is in full force and
effect.
License Nur,4 ic.Class
Cont f ! Date—� `J 7
3_ 1
F1I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus- 8 4 9,$A
iness and Professions Code). PE RiM97 ISSUONG FEE o 0'00 0
Lic.or Reg.No. Date 70TA `FSlc. � # 8
IL
® ® 46,25
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT .
oA—
I hereby affirm that I am exempt from- the Contractor's NAME e e O 4&2 55
License Law for the following reason (Section 7031.5, Busi- `' - 1203 '-"87
ness and Professions Code).: i ADDRESS
.
1, as owner of the property, will do the work and the 11
structure is not intended or offered for sale (Section i'CITY / TEL. NO.
7044,Business and Professions Code).Q OWNER(
I, as owner of the property, am exclusively contracting
With licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there is a construction lending agency _ L ,
for the performance of the work for which this permit isCONTRACTOJ � j_
issued(Sec. 3097,Civ.C.).
Lender's Name J�ADDRESS Lender's Address TY — J �_ /j TEL. NO�/����!`f!"�!f
1 certify that I have read this application and state that the STA FE LIC�i'� r3 c✓rd
above information is correct.I agree to comply with all County LLICENSE NO. _ l.� Z. CLASS ay
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above-mentioned property for
inspe tion purposes. »
Signature of Permittee Date