Loading...
HomeMy WebLinkAbout02_12_1987 - 21015 PATHFINDER RD (4) WORKERS'COMPENSATION�ECLARATION APP"CATION FOR PERMIT � I hereby affkm that 1 hove a cerfificate af consenl fo self � , insure,or o certificate of Workeri Compensarion�nwrance, - HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof(Sec.3800,Lab.C.) � 76A36aC . � . CE�-818(REV.10/81) .' . .� . . . . � POolicy No%�Z76�n'�ompany .�1I,�'�� �. . . � . Certi(ied copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY � ��.Certified copy is filed with�he county buil 'ng i � � - �� FOR APPLICANT TO FILL IN � -� - . BURDwG c� :p tion departmenf. (PRINT OR TVPE ONLY) ADDRESS � d/cJ / �c � Date�J�Z—�� APPIicaM- � - LOCntI7Y m P� NO. NPE OF AP%.IANCE OR EOUIPMENT � FEE CERTIFICATE OF EXEMPTIO OM KERS' . NEARE57 � � COMPENSATION SURA CROSS ST. (Thk ieeNon need not be eompleled i e work Imolvod by ABSORPTION UNIT,BTU' � o�sraicr No. va seo a - 1ha permlt Is for one hundrad dollors(f100)ar lass.) L��(� /� �b � I certify thal in fhe�performanCe of the work for which this � A�R HANDLING UNIT,CFM L' permit is is5oed,I shall nof employ ony penon in ony manner . _ ' so as to betome su6jeU ro rhe Workers'Compensation Laws.._ BOILER,BTU � nvvaovn�5 �ATE INSPECTOR'S SIGNATURE Date Applicant � COMPRESSOR,BTU ROUGH � � NOTICE TO APPLICANT: If, after making this Certifimte of� VENTILA7ION SYSiEM FINAL � Exemp�ion, you should become subjecL to the Workers' Compensarion provisians of the Labor Code,yoo most forth- EyqppRqTIVE COO�ER ' VALIDATION with romply wlth such provisions�or this�permif shall ba . deemedrevoked. � � � PURNACE: � iAU_GRAVIN- ' . . � LICENSED CONiRACTORS DECLARATION . F�ooR� BTu � � I hereby affi�m that I am licensed under p�ovisrons of<hapter 9 HEATER: SUSPENDED UNIT �— - • '(commencing with Secfion 7000)of Division 3 of fhe Business WALL and Professions Coda,and my Ikense Is in full force and effect� � . � . � � � - � �� � � y . . .. Litense Nomber�b���� Lic.Ciass l3� - . - � - ��--� - �-- � , V GC /J��G C�Gsu� �.G,C�.� iG!/ O Contrat�or Date �'���� . ... ... - �-. ❑ I am exempt under Set. � � ... _ . . . . V Plan check fee °� � B.BP.C.for this reason - - y PERMIT ISSUING FEE S / Z � � TOTAL PEE p 3 5 2 0 A Signature - . � � � � R-B ER CLARATION PIAN CHECK APttICANT - . �r• • • •.�S I hereby offirm t at I om eze t from the CoNracror's License low for ihe foltowing reason(Seclion 7031.5, Business and NAME , �� �!G r.y � • '2 Q 5� � Professions CodeJ: - - ❑ I, os owner oi the property,or my employees wilh ADDRESS( - • • •2�.5�� . � woges as their sole compensation,will do tha work and . ��ry - TEt.nt0. �_� �,,.� 0 2� 3—$7 ' the strvcture is not intended or offered for sale(Section 7044,Bosiness and Professions Code). ---- � �+--- -�-- - -- - � � � OWNER �id / O � . .... . ❑ I,as awner of the property,am exdusively contracling MAII- " s � with licensed contractor5�o Construct the project(Sec-- AODRE55 7���Z /�G / JDn/ tioo 7044,Business and Professions Code).-� , _ CONSTRUCTION LENDING AGENCY - - dn -/ ��� �� - �� iet:NO.- - � -� � � . . I hereby affirm that Ihere is a construction lending agency for �he performonce of�he work for whith this permit is itsued-� �ONTRACTOR - �G L �/ � ' �j{�ll-- - ,_ (Sea 3097,Civ.C.). ,,1 �j y� - - � - . . -.. .. , _.. ' - ,.;.... , - � . . ADDRESS '�D U�. GC. t O`U _ ... ...._ . ... . ._ . . - _. . . _ . . . Lender's Name y - � � . . CITY_�(JH.� � � . _ TEL_NO,_�7I"�G _. .._.. _ . .. tender's Address $iATE C UC. �? I certify fhot I have reod this applimtion ond stote Ihot the UCENSE NO. O� CIASSY � -� �-- - � - �- . - � � . - - � - � obove Information is correct.I a e to comply with oll Co�ny ordinances and Sta�e laws r ing 10 boilding construclion, _ � . and hereby authori e re ent ves of.ihis Counry to enter � � � �� � - � ��� � � - �� � -� � � opon the ob ve- n) d p erty for inspeU�on purpozes. SEE REVERSE FOR EXPLANATORY LANGUAGE _ _ ign- re o� �oM o genl Dote _ . .� . . .. .._ ___.. _. _ ._. _ .. . _ . .� _ . ", -� . I � _ti__._ .__I—-- ;S , s r I � ;��, , j . ,� , . , , .,1 . P.. `J �;�✓''''�1 �4� ��{ t . , � . 1 y i! . � � • '� �t��� ��� � �t , � .. �. �. :` ti �}� _ { ,. � r ` f��' � -'� � `� ���; : N ' . . _ _ . s t `, �k - ', ' � .; ' , . � . `•' ', � � •'} . ` �{ � � . .-�,� i • •� ; � �.� . � ' , . . -, . • �� _ �i ., , , - � � � � �� � , '��-. � � ��. _ ' � " � , � : .... . .. ..�._. ...- - . " ' ;` 4 ' __.. t. i ;. -. � � � 1 . ' ' i `� •' . _. _.. ,. , . _ � , � . - . . - . , • _. , , 1 , I ' -- _- ' 't ' '� ;. ' '� - ; � , � �l � � , i ' � 1. f � � � . i �� �� ' ,��� � t +l �i � ' �� O � - ��1 . y � � , �1 '��- �� � � � � . - _ � 1 m _ 1 y . � ; N ; , , � i , '' ' . i - - � i : , _ ;, � : __ • �� _ � � ,� ! - � - i . � 1, �/ , f, �',= - - , � �. � ' . � � ;' � . � � � , - ` � ' . W - , " ' � } , .. ' . . ;� - . .. .. . .� . ' r"' � � •i ` �.o m m � � ._ - r; �:v, n3c �.n � mm . . . .. . ,7 O p O�O n �� � C 3 N m - , ' : . . = O � � ?0 � � w� .0 b N� Q N Q � , . ., . ` V 1 _.. . • N�� O �Q�.. O �2� a � O N '� N �N O(J�'�O.3 n ��.p�,Q Q � O f _ " t • - - - � � , , Q� "� H n �. . Q'�,O Q.F II'� p A „[ o'O Q � .�� � f -.. � ._ � C < q ?C � ,p. -'inO iA p Q. �Sd-O a�GL '�' Q p R°- 3 ov �� �m ❑ Q,c343 0.� ''`� o oo'-'.= �ooTN�N3 �a3 : m � � . , ' �Z W . � - CJ � O • ���rG : � . W -t.N N W _�Q^+<"C � '� O if _n�... p j. �� . . � � � , V � . ^ �7 _� . p (D�� ?O � @�O �O .r- �a.'^�� " —.p Ll 7'�"j .`n O C �-m S p �� IG W N ^I V Q ,�:] 3 �O�D p''� N f� T + p N (p � _ ' . ' O .� . p u � � „' (� O ,O � N �0 �c p O O �7�x.,S'� {p N C � O " C , - ' 9 �� �.;f m £ _oo °.i oa � p o orom-H�r� o m � Noo r- �'� � a o � .. � , ?. . � . '=S'� p w..m ^ m o a.�m o « ��.c, K �y� �'f v c - t�p � � . . _ . . - ,. a �Q- - � O A 'd O < ri 0 Q-m a a.p,,,m 'O� .k i W c S� C 0 f y. �1; . _ . � . � . � O ,< m ? �•..'^ o l9 - �n �v' O.�t W �'� � t1w p ,•^. ry�_W� `�} - �� ' �- � �'.N � �0.3. �.�-o a p aa �.fl ? 3 Ta e� .� a rn _ . , . � .. � Q 'N � ' �Qr-��� �''O��A SO 7 �D .�T�J N"`O a �' b 'b � O �Y m�+ "� , . Z7 � D -S�` � ,N��'3 tl ... � ; , ' . � �,' , i, a o m� o o v � c� ^� �o .K�-o,.m 3 � ;� �-.m � o -r � N i _ �" �bNo;6 � aW �-�> > m'` ° 3 m".°' .o•-oN �_� � - 7p . J ' � _. , ; ' . . - _ . _, .`;. O j�t'�n N �^ O � W O� � N � £ � y� O �N'^.,��''fi.��� u��'36�G 3 � .�I . . . �a a_�'��K °,�'° <�` } o.n.aa o o-°° „ 3� o'�:<-� ^p 0 �t. . , . " .. , . . . , - n Q 7 n p q �� o � � �..� � p,p �3 N O"��t in 3_p ia �.ti O 0 Cl Z . . - . ' ' � , � �W tl�0 ��� O n !7 � 7 "m -..n �. � e:tp.p c O � . . ' _ - • - ' . w 7'�.O+v�_R p �O S�'Q,�.../p� Q �_p'4-.'� � � �- p 7 � 7 . , ,- � � , - ; `,�o m � ^_. ��v �' � °.m f°.� s. •T°'� N a°3"� o° . . . - - . � . p �--7�'+ v. ` mc� 0'Ofl � CNtnW �� O "' O �.S�O � ' . ' - .. , ._ , .'C 3 -O.,rj'.�-< . �.,. _. Q N p �� � a�,�..6"O � a • J � 0��0.'4`G . ?7 7 m N�cp ? O Q•U p N � S�� � ?•?N 4: �n U � � ,`� .. � ' _ . ' � .. t .� >'ui� O��� p 0.?O y. �-•[ o ` 0. Ll�� _. � ,,j� . . .. . � . � �_ � p�' e�.� 7 fl.N ' I _ " ' ,, " . . � K `. �