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HomeMy WebLinkAbout04_17_1985 - 21073 PATHFINDER RD (2) � WORKERS'COMPENSATION DECLARATION � � '�� � 1 hereby affirm thot I have a certificate oF consent to se�f APPLICATION FOR PERMIT insore,or o cerrRmre of Workers'Compensa�ion Insurance; - HEATING -VENTILATING - AIR CONDITIONING � or a certifle cop.thereof(Sec 3800,Lob.C.) 76A36aC -. � � L //�� , �{ CE-818(REV.10/81)� � ..-. . -.. -.- -`�1{ . P❑olicy No[t1.�C�C�pany �NF .. _. . . � . . . � �.a]P�" . Certified topy is hereby furmshed. COUNTY OF LOS ANGELES- BUILDING AND SAFETY �� � Certified copy is tiled with the cou ty bulld�n inspec-• FOR APPLICANT TO FILL IN ButtD�NG 2 � tioenf{1�epJayrfinent, (FRINTORTYPEONLVJ ADDRESS Date -�ApplitaN lOCnt�iY A p��. . NO. TYPE OF qPpLIANCE OR EQUIPMENT� FEE _, CERTIFICATE OF EXEMPTION FROM WORKERS' , - NEnREST , � � COMPENSATION INSURANCE CROSS SL � (Thit s�ction nead nm be completed fi Ihe work Involvad by ABSORPTION UNIT,BTU � � orsraia No. vRocesseo fhe permH(s(or one h�ndrad dollars[SI00)or less.) � - . � � C�� I certify thot in the performante of the work for wh(ch this. AIR HANDLING UNIT,CFM permit is issued,I shall nol employ ony person in ony monner so os to become subject fo the Workers'Compensation laws.., BOILER,BTU APPROVAlS DATE �NSPECTOR'SSIGNATVRE � — Dafe Qpplicanf � � COMPRESSOR,BTU � ROUGH� . NOTICE TO APPLICANT: If,�after making this Cerlificate of /L VENTILATION SijTAlf�� 2 .,.� FINAL �j� Examption, you should become subjett to the Workers' . � Compensalion provisions of the Labor Code,you most forlh- EVAPORATIVE COOLER - VALIDATION - with tomply wi�h such provistons�or lhis permil shall be _ deemed revaked. � . ' FURNACE: FAU_GRAVITV - �-' IICENSED CONTRACTORS DECIARATION FtOOR eTU - � I hereby offirm that I om licensed under provisions of Chapfer 9 � SUSPEnIDED - �� UH�T_ � -� • '(commencing wi�h SeUion 7000)of Division 3 of Ihe Bosiness HEATER: wau . � � and Professioos Code,ond my license is in full force and eifed. � �! � - - . � �" N� �� � O _ Ucense Number Lic.Class� - G - -- � �� n; - , � � �J �� ��, �,� G� 1 � Comrattor pote�LL'iL / �is � � � 10 Q I am exempt�nder Sec. w . Plan check fee a N 8.8P.C.for+his reason' . pERMIT ISSUING FEE S ,SD �„/ z — Date: TOTAL FEE �� �— SignaWre ' ' . _ . , ��E7�j�I�/L . . OWNER-BUILDER DECLARATION PLAN CHEIX AVPLiCANT r �� Q O � I 1 hereby af(irm that I am exempt from ihe Contractor's License - - � �' . Law for ihe following reason(Section 703I.5,Business and NAME . � � - Prafessians Code): � . ' � " . ❑ I, as owner oi the property, o��my employees wilh A��RESS . - wages as their sole compensatian,will do rhe work ond � � the strudure is not intended or offered for sala(Section CITY TEL NO. � 7044,Business and Professions Code). - J -�- OV✓NER G ❑ I,as owner of ihe property,am exclusively contracting . � with licensed mntrac�ors lo construtt the project(Seo- ��� �" --- - - - . lion 7044,Bos��ess and ProfeSsions Code). ADDRE55 rrC'�Ly ��4 0 2 6 A � CONSTRUCTION LENDING AGENCY �iTy J�(�- � TEL NO. �- - �- -� ��' - � �8 I hereby affirm�lhat�here is a constrocflon lending agency for � �� , • •� the performante of fhe work for whicb this permil is issued CONTknCiOR � - -� -�� --� - (Sec.3097.Civ.C.). . . Q//' . . ....-�---- -- -_. _ ._.. _ I • � 627.Jr . ' � AD�RE55 ^ ' ' Lender's Name � ��v . ... . . . . ' • • 1-b 2 7��, - Lender's Address � - ' - CITY � �_/ ^ TEL NO.. ^"CIS . . � _... _ ... . .. . ..� , STATE �ly� �,c. " 0 4 1 8-8 5 , I certify ihat I h e rea this application ond state Ihot ihe LiCENSE NO. �lil.�y�� QASS- ���.O ...._ .._ . ._ . . . . _ ... v6ove informa" n is mrr ct.I agree to omply with oll Covnty . �rdinonces d State I s rela�in ilding conshodion, � - � � , md hereb aurhoAze.epresenf v this Cou ty to enter . � � � -�-� � � � ` �-- � �-- � �"' � � - - �pon the ove-me io p. or fnsp'ettt n pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE 'Y /� - naiure of Appii • Do�e� . . . . .. . . .. . ... ...._. . . . __. .._. .._' .. ... . .:.. ... . . .. . . r _ - � . �J - � �,�-- �- J . _ .�� � �� � _ , _ r_ �-�--,, , ; � � i � 1 �'. ?�J I ,, , y�` `�� � , ` �;;�� � } i �r' � ��i . � i; i � - - `` , -= � ' :i, `,�, r �.; . � . , ' �,, l ,,� � _ " ' � - �''�;' " ''' ; C? f V . , � ;-� ' ic, .- � � � .t� � � � i _� '� r1 i.%;f t ;' � f� ,'� ��;; � � -i , �; m , � '� > > . � � �, ',, � ,:• ��r;i � . , , �_ t � •�� i � t � . 70 f!.�� � �i � ��, ��' J �' �;�.�. E ,_ �r,: . . 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