HomeMy Public PortalAbout6149 KAUFFMAN AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9,69
I hereby affirm that I have a certificate of consent to self insure, APPLICATION FOR PERMIT
76A364C L I E GREEN,
or a certificate of Worker's Compensation Insurance, or a certified HEATING,-VENTILATING -AIR CONDITIONING
coWthore, �]Se 800Lab. C.)`" Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
Certified copy is filed with the my buildingAtiection FOR APPLICANT TO FILL IN BUIL
D
�1department. (PRINT OR TYPE ONLY) ADDRESS
l _/ (— [Z A lican LOCALITY I
Date pp NO. TYPE OF APPLIANCE OR EQUIPMENT FEE •
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. TAf
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($100)or less.) I AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws. (/
COMPRESSOR,BTU
' APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL ` -
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTu VA IDA`TION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
ISTU_
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License Number S`?(o 7 6 �l Lic.Class CIZO
_ 30-" ^
IL
ContractDate �^ `/ - _ :.: U
Plan check fee
❑ 1 am exempt under Sec. t_E!„ ! •T-g-;,j O
B.&P.C.for this reason
PERMIT ISSUING FEE$
Date: TOTAL FEE (.Iii sib_ W
IR.
Signature PLAN CHECK APPLICANT CD
OWNER-BUILDER DECLARATION Z
I hereby affirm that I am exempt from the Contractor's License Law NAME ► Ii„_I': '.`•;3(_!4
for the following reason (Section 7031.5, Business and Professions '
Code): ADDRESS »6-L 1 H1 f ii
❑ I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO.
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 CTS�� ) �F
with licensed contractors to construct the project (Sec- ADDRESS �W►✓v�—
tion 7044, Business and Professions Code).
CITY TEL.NO.
CONSTRUCTION LENDING AGENCY
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 _
CITYTEL. O.?3 0/
Lender's Address STATE L LIC. U v -
I certify that I have read this application and state that the above LICENSE NO.i S &' CLASS
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of is County to enter upon the above-mentioned
,prVp ty for insp tion urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ATURE OF APPLICANT OR AGE DATE
.5
4
76A36 .-CE8.1`8-x+..-68 APPLICATION FOR 'PERM T
~. <<• HEATING - VENTILATING - AIR-CONDITIONING'
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER BUILDING .
BUILDING AND SAFETY DIVISION ADDRESS -
JOHN A. LAMBIE, COUNTY',ENGINEER
COLEMAN W. JENKINS, SUPERINTENDENT OF BUILDING LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. .
(Print or'type only)
OWNER
NO. -TYPEjOPAPPLIANCE OR EQUIPMENT, FEE
MAIL
ADDRESS
ABSORPTION`SYSTEM, BTU CI Y' NO. -/'
JF
AIR.HANDLING UNIT, CFM'- CONTRACTOR 0�
BOILER, HORSEPOWER ADDRESS
COMPRESSOR,-HORSEPOWER CITY TEL. NO: "
STATE y LIC.._
VENTILATION SYSTEM LICENSE NO. CLASS,
DISTRICT NO. GROUP' ZONE'' PROCESS BY
EVAPORATIVE COOLFR
FURNACE: F.AU GRAVITY f' >
FLOOR
FLOOR—BTUJ f INSPECTION RECORD O
U
HEATER: SUSPENDED UNIT '
WALL O
-, -- - U
cn
" Z
NEW—ADDITION— PERMIT $ 3 00
ALTER—REPAIR— TOTAL FEE $ '
IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE-THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY -
WITLOFCHAPTER
ACOUNTY ORDINANCES AND STATE, LAWS REGULATING
ENTILATING, AIR CONDITIONING.
I ..
BY CERTIFY THAT I AM NOT, ACTING IN-VIOLATION
9, DIVISION 3, OF THE BUSINESS AND PROFESSIONAL
E STATE OF CALIFORNIA, APPROVALS -D'ATE INSPECTOR'S SIGNATURE
E ``' � ROUGHTTEE
FI NAL
IDATION - JACK R. ALLEN'
CK. M.O. CASH SUPERVISING MECHANICAL ENG'R.
r7
Lam, 1 18� NOV 4 4-1 ,a 7,Q 0N 9
,SEE BACK OF APPLICATION FOR COMPLETE FEE SCHEDULE,