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HomeMy Public PortalAbout6032 KAUFFMAN AVE_Mechanical__ N/ORKER'SCOMPENSATIOe of consentDECLARATION to 76A346DPW9/69 APPLICATION FOR PERMIT LIME GREEN ' 76A364C I hereby of/'!rrtv tha=,,have &certificate of consent to self insure, or 4 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. Certified copy is hereby furnished.. Certified copy is filed with the county building inspection FOR'APPLICANT TO FILL IN BUILDING.ADDRESS department. (PRINT OR TYPE ONLY) LOCALITY Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. G!''.- COMPENSATION INSURANCE 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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU .�� become subject to the Workers' Compens Laws. �y COMPRESSOR,BTU v �O14 _ APPROVALS DATE INSPECTOR'S SIGNATURE Date• �7 Applica - VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certfficate of ROUGH Exemption,you should'become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY r LICENSED CONTRACTORS DECLARATION FLOOR BTU 2 VALIDATION I.hereby affirm that-] am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000) of Division 3 of the Business and HEATER: WALL -• Professions Code, and my license is in full force and effect. Sb 70 /© - � 1 License Number � Lia Class , �'• 2 T—� 5::{:: o a Contracto Date - Z. `t_ I am exempt under Sec. Plan Check-fee :r--- —�_ _ tzU B.&P.C.for this reason PERMIT ISSUING FEE$ ?I'')` O 34 40 TOTAL FEE d/0. LLI Signature i,HEC'{. PLAN CHECK APPLICANT OWNER-BUILDER DECLARATION s_-;H(aNG Z I hereby affirm that I am exempt from the Contractor's License Law NAME s� f Poo- for for the following reason (Section 7031.5, Business and Professions Code): ADDRESS 1, as as owner of the property, or my employees with wages fi F-0"0431 as their sole compensation, will do the work and the CITY TEL.NO. , SZ "=t; h_' "_ structure is not intended or offered for sale (Section 7044, �' ` �� 7 #a t - Business and Professions Code). OWN �. .f • ❑ I, as owner of the property, am exclusively contracting MAIL ' -07 with licensed contractors to construct the project (Sec- ADDRESS/�o tion 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY P tt { TEL.N0�1�'_-y03/G,l I herpeby affirm that there is a construction lending agency for CONTRACTOR the erforermlt Is issued mance of the work for which this (Sec.3097, Civ.C.). ADDRESS Lender's Name CITY TEL.NO. Lender's Address STATE /( � i+ LIC. I certify that I have read this application and state that the above LICENSE NO. (� G 6 CLASS 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 f inspection pur SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF APPLICANT OR AGENT DATE