HomeMy Public PortalAbout6202 KAUFFMAN AVE_Mechanical__ WORKERS'COMPENSATION'DECLARATION APPLICXION FOR PERMIT
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I hereby affirm that I have a certificate of consent to self - , 1.
`insure,.or a certificate of Workers' Compensation Insurance, - - HEATING -,-VENTILAT'ING '- AIR CONDITIONING
or-a certified copy•thereof (Sec. 3800, Lab C ) 76A364C u
CE='818(REV' 10/81)
Policy No. Company
Certified copy is hereby furnished. COUNTY OF-LOS ANGELES BUILDING AND SAFETY
❑; Certified copy is filed with the county,building inspec- --FOR APPLICANT TO FILL-IN- BUILDING
tion department (PRINT OR TYPE ONLY) .ADDRESS W.M. f/O
LOCALIT`A°
Date Applicant W�9 �NO TYPE-OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS_. NEARESSTIGYrf�R�'e
COMPENSATION INSURANCE
ABSORPTION UNIT., BTU
neeDISTRICT O' PROCESSED BY
(This section d'not be• m
copleted if the work involved'b'y NN
the permit is for one„hundreddollars ($100)or less.)
I certify that in the'performance of'the•work'for which this. AIR HANDLING UNIT, CFM- ��/��
permit is Issued, I shall not employ any person in any manner V
BOILER, BTU
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so as to become siiblect to the Workers'Compensation LAWS _ APPROVALS DATE INSPEC R'S'SIGNATURE,
'COMPRESSOR, BTU, ROUGH
Date Air pplicantLsE�1n� �
NOTICE TO APPLICANT: If; after making this• Certificate of VENTILATION SYSTEM FINAL . 14
Exemption; you 'should become subject to the'Workers' , ° r
Compensation provisions'of the-Labor Code, you must forth- EVAPORATIVE COOLER VACIDATIQM
with comply with"such provision ,s"or this_permit shall be
deemed revoked. FURNACE FAU GRAVITY
. LICENSED-CONTRACTORS DECLARATION FLOOR BTU
I'hereby affirm'thatd am licensed under provisions of Chapter 9 HEATER SUSPENDS UNIT
(commencing with Section 7000) of Division 3 of the Business WALL-
and Professions Code, and my license'is in full-force and effect: d
. - - 0 ,
License Number "'Lic' Class 4 $
OC'
Contractor 'Date - 0
❑ ',I a'm exempt under Sec. 2 7 4 9 A
B.&P.C. for this reason U.
U
Plan check fee' y
} - PERMIT ISSUING FEE $ # o o a a 98 _
'Date:
Signature TOTAL FEE
I e20,SO
- ..
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT '
I hereby affirm that I am exempt from the Contractor's License o.0 '-20.5,05-
�?ons
the following reason (Section 7031.5, Business and NAME ” ►
Prof
Code.) 0 2 O.-85
as owner of the property, or my employees'with ADDRESS -
wages as-their•sole•compensation,will do the.work'arid` CITY TEL NO
The structure is not-intended or offered for sale(Section
7044, Business and Professions Code) -
❑ I, as owner of the property, am exclUsrvely contracting OWNER
with licensed contractors to construct the proIect•(Sec-
MAIL
tion 7044;-.Business and Professions-Code) ADDRESS' '
CONSTRUCTION,LENDING AGENCY CITY TEL NO '
I hereby',affirm'that there is a cor structlon lending agency for
'the performance of.the work for_which this permit is issued, 'CONTRACTOR
(Sec. 3097, Civ 'C,)
ADDRESS
Lender's Name
CITY TEL NO
Lender's Address
that'I have read this application and state that the . STATE LIC
I ceitif `
y' pp LICENSE NO- CLASS _.
above information is correct I agree to comply with all-County
ordinances'and State laws relating•to building construction,
and'hereby authorize r sentatives of this County to enter
uKt►n the ab e-mentio e property for inspection p oses, SEE REVERSE FOR EXPLANATORY LANGUAGE
qAa
Signature of Applicant or Agent Date - ,