HomeMy Public PortalAbout6218 KAUFFMAN AVE_Mechanical__ WORKERS'COMPENSATION DECLARA CION CEA 818',2-86)
APP LICA Y i®1 tl FOR P E R•V�fr T J
I hereby affirm that I•have a' certificate of co�r SON
to self
insure,-or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
certified copy thereof(Sec. 3800,Lab. C.) •
Policy No: Company
COUNTY OF LOS-ANGELES. BUILDIKIG AND SAFETY
Fl. Certified copy is hereby furnished. - ' ' � -
Certified copy is filed with the county building inspection BUILDING r
departmentp FOR APPLICANT TO FILL IN ADDRESS
Date* Applicant t /`��lt" .�► 'i / � _
(PRINT OR TYPE ONLY) ��� f�
_
LOCALITY_
-CERTIFICATE
�r- ,
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE'O•F APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST k �-
(This section need not be,completed if the-work. involved ABSORPTION UNIT, BTU CROSS ST. �-=c%!' jP�•,t�d 11
-O
by the permit js fot one hundred dollars ($100) Or less.) r DISTRICT NO. PROCESSED BY C)
I certify,that in the performance of the work for which this AIR HANDLING UNIT,CFM ). O
LS permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers�Cpinpensation Laws. BOILER, BTU
•l- - APPROVALS `DATE,- INSPECTOR'S SIGNATURE ILJU
Date l'�°�'<'A licant tom.'/✓i� / /�1�/�'r / r d�' to
PP �'�� f— COMPRESSOR, BTU—Z ROUGH'
NOTICE TO APPLICANT: If, after makjng this Certificate of VENTILATION SYSTEMZ
Exemption, you, should become subject "to the Workers' FINAL a�
Compensation ,provisions of the Laboc Code, you must forth- EVAPORATIVE COOLER: VALIDATION
with,comply'with such provisions or this permit-shall be r'
deemed revoked. FURNACE: FAU GRAVIT
- t
-
LICENSED CONTRACTORS DECLARATION FLOOR: BTU r
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- WALL
ness•and'Professions Code, and my license is.in full force and r.
effect.
License Numbery C�� I ic.Class
C2
Contractors
0. I`am exempt from the licensing requirements as I am a
- licensed architect or a registered professional engineer Plan check fee 25%of above.
acfing in_my professional capacity (Section 7051, Bus- s.
iness'and Professions Code). PERMIT'ISSUING FEE $ .rd
Lic.or Reg.No. Date TOTAL FEE i3. Sd t•
• HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I:•herebq affirm that'I ain exbmpt from- the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Codi): ADDRESS
❑ J, as owner'of the property, will do the work and the 7 9 U A
structure is not, intended or offered for sale Section
CITY TEL. NO.
7044, Business 9nd'Profe5sions Code). ( � I o fo o o 0 8
Q' OWNER /9t lfi��✓ ��. /t CSC,/C�
I,•as owner of the property, am, exclusively contractingp•t'
'with• licensed contractors to construct the ro ect' MAIL / 2.°r°;$'3 J�
(Section 7044, Business and Professions Code). P 1 ADDRESS�!�l F.t��t� ��y `�10: ' ; lr
'CONSTRUCTION LENDING AGENCYCITY' TEL.NO. � —(�� o o e 8�.�•Q v
I hereby affirm that there' is a construction lending agencyr�,2.9—8 2
p for-the performance of the work for which this permit is ' CONTRACTORv�J2�li ly �rit% �y9G
issued(Sec:3697,Civ.C.)..
Lender's Name ADDRESS
Lender's Address CITYS�• �7/7 .�^y�/��jct.N0:3,5S=�Oe7�
I certify that I have read this application and state that -the STATE C / LIC. ^7
above information is correctJI agree to comply with all County L'I ENSE NO. 7C7� CLASS 6>
above
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 abov -mentioned property for
inspe hon purposes.
1Signature of rmitte��Date
Pe _ _