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11_16_1984 - 21015 PATHFINDER RD
WORKERS'COMPENSAT�ON DECIARATION APPLICATION FOR PERMIT 'I � ereby affkm that I have a certificate o(consent to self . sure,or a certifitate qf Worken'Compeniafion i�s�.a��a, ;� HEATING --VENTILATING • AIR CONDITIONING �� r a certified copy thereof(Sec.3800,lab.C.) 76A364C _ . A CE-B18(REV.10/81 j POolicy No���Tompany �F�"1�� . _ . .. .. .._. . Cerfified topy�s hereby furnished. COUNTY OF LOS ANGELES BUIL�ING AND SAFETY � Cer�ified copy.is filed with the munly building inspeo- � POR APPLIGANT TO Flll IN BUItDiNG tion department. � � (PRINT OR TVPE ONLYJ � ADDRE55 �/D�s �-AZ��/N �,�, Dole I!-I�u"'�'TApplicant �_'^�^"�-�jr`� NO. TYPE OF APPLIANCE OR E�UIPMENT . . . FEE LOCALITY >^n,s.�� �3�(� C/) . ., � � CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST s� �w� � COMPENSATION WSURANCE � . CROSSST. It f�efion naad nof hQ wmpleted if the work Involved by ABSORPTION UNIT,BTU pi5iai�r rao,./1 vop�E55ED �. . Ih�p if Is lor one hundred dollars(5100�ot(otf.)� AIR HAN�LING UNIT,CFM �-.y�+ 1 certify tha ' the performonce of the work for which this U _ permil is issued, II not employ any person in any m er BOILER,BTU — ��-so as fo 6ecome subjec the Workers'Compe 11�4WS. APPROVAlS DAiE INSGEROR'S SIGNATURE ' �' COMPRESSOR,BTU I�DNj"'JJ�OUM �D Q[1 ROUGH � . Da1e - � APPlicant� . - . NOT�CE TO APPLICANT: ter moking is Certifimte of � VENTILAT�ON SYSTEM � ' /Jt 0�S FiNnL (a � � Ezemption, yov�s become subjecl to e Workers' �K Compensafio ovisions of�he lobor Code,'you forih- � Evnvoennve coo�ea VALIDATION � � with y with soth provisions or this permit sha . � ed revoked. � � � FURNALE: FAU_GRAVITY . � ` � IICENSEU GONTRACTORS DECLARATION ftOOR BTU I he�eby olfirm thot I am licensed under provisions of Chopter 9 HEATErt: � SUSveN�E� UNIT_ - . '(commencing with$ectlon 7000)of Division 3 of the Bosiness � WAIt ond Professions Code,and my license is in foll force ond effect. - " J�M ' � �. .Cr+�i�A�N=G'Py.�'� ZC+ L�O a LicenseNumber�v22«D .... - O u�.cio5� GZd � �+7 �^a�77d��rs r�- 7� �, oe �' „u+; H-!l�.•�� }� / � ' Contmctor_,�1�/4M• � Date / IU1'D tY�/7MU -/�6i�yT.� OO � ;^,9 7 Q,�]F{ V . ❑ -I om exempt under Sec - � .- . . . 3 � y Plan check fee Q �(.� ff.`. • •22 „� B.BP.C.for this reason� � 2 �afa: PERMIT ISSUING F � ���7 9 9� TOTAL FEE Signo e - - " � - � •7p.(�0� NER-BUIL�ER DECLARATION � PInN CtiECK APttICANT������ (.v�, � �' � I hereby affirm thai m exemp�from the C tratror's license � . � � 1.�1 6-f3 4 law for the following asan(Section 7 1.5,Business and NnM �f�y���� �p � . Professions Code): - � - - � ADDRESS l ,�J _. . ❑ �, as owner of the pro r1 or my employees with • - . , wages as their sole tompe �ion,will do the work ond ' �-+Y ��{ � Ql 2 `�r�i� ihe sfrucfure is nol inte d o ffered for sale(Setlion ��ry>• .�it��'li�vTl� TEL.NO 70dA,Business and P ess�ons de). � pWNER � � yiG/_��+ b �' ❑ I,as owne�of fh roperty,am exc sively contracting MA L . wiih licensed c fmctors to construct e projed(Set-�� pDDRE55 � }�^ � 0� ' I tion 7044,Bu nesT and Pro{essions Co � . �9�I 9.H A CO RUCTION LENDING AGENCY . -- CiN �St/��j - �- -ieL.NO ?� �Od � : � I hereby aifir o�there is a canstruUion lending ency(or � � • • •.' 'a � the perform ce of fhe work for which Ihis permil iss�ed CONTRnCiOR �y��� - - �-� - , '" (Sec.3D97 iv.C.J. �- - -_._ . .. . .... .... I � � 7 Q 2 J_ .. lend s Name � � ADDRESS l33G 7� ' . . .. � - •.� 7���� ._ , . � . . CITY � � ! /�N'T7E .. .TEL NQ!f,{� � . . . . . . . • . , Lender's Address �� � � " I�1,1 6-8 4.� �_�� , p _ �.. I certiiy Ihot I have read�his opplication and state thaf the �CENSE NO. CQ 2� ClASS �iC/�����-�� �� -�-- - �-� --- -�- - • �-- - - '� �- �� above information is corrett.I ag�ee to comply wilh all Co�nry , �ordinances and State IowS relat(ng 10 building tonStruUion. : . . . , ' . . __ __ ... ... . ...._ . . . . ._ .... . _ _. _ ... ond hereby authorize representatives of this Counry to enter . � . . upo(n ihe nabove-menrioned properry for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE .. _ �]�u�iia�� - . . . _._..---. _. .._ . �_ ..-. ..._._... .�_ . . _ L����.+'��.. . . � - - _ _ " Signature of Applimnt or Agenr ' ��a � - .� ...... �' �.. �.... � � ;� � � � - ', + - � � ' •�i , _ � �1�� ,�� i � ���` '•� , � a: :� � l�� � �c . '�, � i � � � � �1�� ' � �� �t. �� .._ � , �, , `� ' � � �,�1�' y". � f .r �(� . . ` �"/�� ('��/. `.�., � `. 'F � '�t�' : ��1�. � \� � �` e " �' •, ,1,./ y � .� '�l r y' v. . � � ` i ' � . . ` ' ' , . . 1• . ',� i . : ' y-. .. y� . 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