HomeMy Public PortalAbout6230 KAUFFMAN AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C `
I bar.n:firm that I have a certificate of consent to self CE-818 (2-80) �'If� lL��.���.�®0 rl ®� 'U tlVU ��'
insure, ora certificate of Workers'Compensation Insurance,of HEATING-VE:NYILATI NG-AIR CONDITIONING
a-certit'ied copy thereof(Sec. 3800,Lab.C.)
Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
rCertified copy is hereby furnished.
Certified copy is filed with the.county building inspectionF-77-7BUILDING /
dep6artment. _ FOR APPLICANT TO FILL IN ADDRESS 0
Date Applicant (PRINT OR TYPE ONLY)
LOCALITY'
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE '
COMPENSATION INSURANCE r - ' NEAREST }
CL
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. D� `C O
by, the,permit is far one hundred dollars ($100) or (BSS.) DISTRICT NO. , 'PROCESSED 0Y (�
I certify,that in'the performance of the work for which this AIR HANDLING UNIT,CFMcc
permit,'is issued, I shall not employ any'person in any manner O
so as to become subject to the Workers'•Compe sation•Laws. ,BOILER, BTU
APPROVALS DATE INSPE R'S SIGNATO E ' `UL
f ����}}yy--�� v
Dak; Applican i l / COMPRESSOR, BTU-_J �®� �aROUGH _ Cn
/-- % CA
NOTICE TO APPLICANT. If, after making this Certificate of VENTILATION SYST„E,M Z
Exemption, you should _.become subject, to the Workers' FINAL —
Compensation provi'sion's of the Labor Code,,you rnust,forth'-
with comply with such. provisions or this permit shall be EVAPORATIVE COOLER VALID ON
-deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR' TU ��_
I hereby affirm.that I-amlicensed under;prodisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Busi- WALL
ness and Professions Code, and myAicense is in full force and ;
effect. '� /� 7
License NumklW4_; G Lie.Class
�QIttr ,
El, 1'am exempt from.the lice mg requirements as I am a t .
licensed•architect or'a registered professional engineer Plan check fee 25%of above, ��77 QQI1 pp
actink.in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT:ISSUING FEE$��
tiic.or Reg.No. Date. TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN_CHECK APPUCA`NT ., ;o q $
I hereby affirm that 1 am exempt froin=-the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS
I,-as'owner of the'pr'operty, will do the work and the TEL. NO.
structure is not intended or offered for sale (Section CITY-
7044, Business and Professions'Code).
OWNER
I,”as owner of the property, am exclusively contracting w
with licensed contractors to construct the project ' 'MAIL ��
(Section 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY c'IT'rf` 'NO ��
I hereby affirm that there is a construction lending•agency.- CONTRACTOR
for the performance of the work for which this permit is +
issued'(Sec. 3097,Civ.C.).
Lender's Name ADDRESS
Lender's Address CITY A• ' '
I certify that I have read this application,and state that the STATE C•
above'information is correct.I agree to comply with all County LICENSE NO. CLAS/ �
ordinances and State laws'regulating Heating, Ventilating and
Air Conditioning,and,hereby authorize representatives of this SEE,REVERSE FOR EXPLANATORY;LANGUAGE
County puenter up Me above-mentioned property for
i c ion rp
Signature of Permittee. Date
76-A364 _ CE,8.18-1/75
APPLICATION FOR PERMIT..,, ., ;
` . HEATING - VENTILATING, AIR CON011'10'NING
COUNTY OF LOS ANGELES BUILDING' � /`
DEPARTMENT OF COUNTY ENGINEER ADDRESS ` �i�tF{.t/
BUILDING'AND SAFETY DIVISION '
LOCALITY :.�'�T
- NEAREST
CROSS ST. 2 �'
r b
FOR A'P'PLICANT TO FILL INwNEF� —
(P,RINT OR .TYPE ONLY) _ -9 _ a _
_MAIL -
NO •TYPE&SIZE-OF EQUIPMENT„ -FEE, , ADDRESS: '
SEE BACK OF•F1_PPL•ICATIO_N
CITY r, TEL.-'NO. -
FORCE-AIR'FURNACE, BTU
CONTRACTOR' 1 -�
:COMPRESSOR,.BTU '
ADDRESS a
m le
VENTILATION"FANr
CITY TEL. N0�3?_ ! `
LI STATE L
IC.
ST ALL'OTHERS BELOW � "� •' " '
LICENSE NO. CLASS C`Z'CJ
_ -
DISTRICT NO. GROUP ON ROCESS BY, ,
INSPECTION.RECO.RD _
F_
LLI
CL
Plan check fee. See reverse. Cn
Z.
YI_R\'IIT LStiIANC FF E S o =`
sD
'PLAN CHECK APPLICANT
NAME
ADDRESS
CITY T.EL.NO
Mill
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS,APPLICATION - -
'AND STATE'THAT THE'ASOVE IS CORRECT AND"AGREE TO-COMPLY
WITH, ALL ORDINANCES AND LAWS REGULATING,HEATING, VENTI- APPROVALS .DATE• INSPECT R'S.SIGN REQ-
".CATING,'AIR CONDITIONING, ' -
, ., ROUGH_ t
I HERE B•YA TN
- CERT THAM NOT ACTING IN VIOLATIO _
OF CHAPTER 9, DI SIGN 3, OF THE BUSINESS A PROF,ESSIONA'L FINAL
CODE OF-THE ST E F CAL RNIA. ` '< ^
SIGNATURE ,ERMIT VALIDATION ' cK. •M'0. CASH •;, .,'
OF-•PERMITTEE .. a '
PLAN CHECK VALIDATION ;CK. M 0. CASH
3 8 F3,�CEO 2-641 D ' . 7.5 0 La,3o
//2
76A364C
CE-818 IREV 6/78)
os APPLICATION F,OR',PERMIT r
HEATING - VENT'ILATING'--, AIR-CONDITIONING
COUNTY OF-LOS ANGELES ' BUILDING AND'SAFETY-
BUILDING
FOR APPLICANT TO FILL IN, ADDRESS
(PRINT OR TYPE ONLY) = J
NO 'TYPE OF APPLIANCE OR EQUIPMENT, FEE
NEAREST,
' CROSS ST.
ABSORPTION UNIT,BTU I �, ,
.. OWNER r
AIR HANDLING UNIT,CFM _ •MAIL
'ADDRES J "a 1J
BOILER,BTU CIT ,rW TEL N2MawlrL_ [L'
COMPRESSOR,BTU - •• CONTRACTOR T
VENTILATION SYSTEM'S ADDRESS .
EVAPORATIVE COOLER _ CITY
TEL NO -
FURNACE FAU- GRAVITY - STATE LIC '
FLOOR BTU - LICENSE NO CLASS ,
HEATER SUSPENDED UNIT_ APPROVALS DATE INSPECTOR'S SIGNATURE
WALL
ROUGH e�
-- a
8/� ��r� J� FINAL' I 2�
L/ ffL v.gra/- . . ' NSPE TIO RECORD
, LIG•�- i �....�r�<� "
ag
PIan,check fee 25%of above.
PERMIT ISSUING FEE$ � z
TOTAL FEE,
PLAN CHECK APPLICANT 1 PLAN CHECK VALIDATION
NAME r
ADDRESS '
CITY- TEL;NO.
IHEREBY ACKNOWLEDGE THAT'I HAVE READ THIS APPLICATION AND ..
STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL - m r 9 >7 �{ ;
.ORDINANCES AND LAWS REGULATING HEATING,. VENTILATING,' AIR -
CONDITIONING ' -
I,HER CERT Y THAT AM INC'IN VIO �A'
ION OF PERMIT VALIDATION 0 0 0 04 j
CHAPTER 9 DIVISION' ;'OFT BUST SS• RO SS L CODE - - n
OF THE STA OF CALI ORNIA Z o o 2 7,`'
SIGNATURE
OF PERMITTEE ,, '- o ° 0 1 �'m
DISTRICT NO - PROCESSED BYY„ �•
s