HomeMy Public PortalAbout6114 KAUFFMAN AVE_Mechanical__ WORKERS',COMPENSATION DECLARATION CEA 81864C(2 80) APP 1ST C A T�®II'Cl FOR PERMIT
I hereby affirm that 'I Nave a' certificate of consent to self
insure, or a certificate-of Workers'Compensation-Insurance,or Q IIEATIN�y_�!(E(VYILLd►YINCy_i�IL� COW®IYIOi�C6�lCv
a certified copy thereof(Sec.3800,Lab.C•)' .
Policy No.—Company COUNTY OF LOS ANGELS � ,,BUI•L-DING AND SAFETY
❑ Certified copy,is hereby furnished. `,®/ t—�
• ❑
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
department.
Date Applicant (PRINT OR TYPE.•ONLY) ADDRESS
f
F;EE LOCALITY
I:
CERTIFICATE OF EXEMPTION ROM WORKERS' -NO. TYPE OF APPLIANCE OR EQUIPMENT:
COM PENSATION'INSURANCE NEAREST,
CROSS ST.
(This' section h► ed not be completed if the work involved ABSORPTION UNIT, BTU
by'the permit is, for: one hundred dollars ($100) or less.) DISTRICT NO. P ssE r U
I certify that in'the performance of the'work for'which this. AIR HANDLING UNIT,CFM
permit-is issued, f shall not employ anY"person,in any manner
so as to become subject to tht; Workers'Compensation'Laws. BOILER, BTU
APPROVALS DATE INSPECTOR'S SIGN Ai URE
LU
Date"r Applicant - --L—,COMPRESSOR,BTU- CL
n t(
ROUGH'" o
NOTICE TO AP�L)CANT-.-If, after making this Certificate of -VENTILATION.SYSTENI Z'
Exemption, you -should "become subject to the Workers' t FINAL. — -
Compensatiomprovisions-of the Labor Code, you'must-forth EVAPORATIVE COOLER• VALIDATIQN
with comply' ivitp such provisions or this permit shall be
deemed revoked. ) FURNACE: FAU_ GRAVITYy^�
LIC$NSEp CON TRACTORS DECLARATION /:• ' FLOOR: BTU�_(f�( �—�V C/CJ
I hereby affirm that I am licensed under provisions of Chapter - 'HEATER-
I UNIT.
9 (commencing witti'Section 7000),of Division 3 of the Busi- .:WALL f-
ness and Professions Code, and tny_ltcense is in,full for.ce and
effect.
License Nutnber Lic.Class-
Contractor Date
❑ I am exempt froth the licensing,regdirements as 1 am a. •Bus-
licensed architect or a'registered professional engineer P& check fee 25%of above.
• acting in my professional capacity (Section 7051,inessand-Professions Code)- PERMIT ISSUING FEE
Lic.of Reg.No. 'Date TOTAL FEE•'
HOME OWNER-BUILDER DECLARATION PLAN'CHECK APPLICANT
. I hereby ffirfn haat I-am exempt from-the Contractor's - NAME
License maw for 4he f41lowing reason (Section 7031.5, $usi
ness .�d Professions Cods): ADDRESS
_ OFF
tea 2`���.3.8:5 0,
Ci, aowner of,the property, will do the-work and the f z-,� '
� structure is n8t intended .or offered for sale (Section CITY� � Gi� f TEL. NO.', e�,o Q ,j Q,�_
7044, Business and ProfessionB Cade): yY. + 1
OWNER O'4, 2,��� ,
❑ I, as owner,of the property,,am exclusively contracting- s _
-with licensed-contractors to construct the. project MAIL'.
(Section 7044, Business and Professions Code). ADDRESS
,CO�ISTRUCI'ION LENDING AGENCY CITY - E :. O. A '
I hereby affirm that there is a con truction lending'agency •CONTRACT.OR `
for Che-performance of` the work for which-this permit is
issued Stec.3097,Civ.C,).
Lender s,Name' ADDRESS
--------------
* -
Lender's-Address CITY_ ;TEL.•NO..
.•-
I certify that I heve-,read•-this application ,and state that the STATE• LIC. '
above information is correct,j agree to comply_with all County LICENSE NO. CLASS
ordinances and State laws regulating Heafing,Ventilating'and ;
Air Conditioning, and Kereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
.County. to enter upon the above-mentioned proper for
ui�petion �ro� s �j� -
Signature of Permittee Date