Loading...
HomeMy WebLinkAbout04_24_1987 - 21073 PATHFINDER RD WORKERS'COMPENSATIONDECLARATION o{� . - � APPLICATION FOR PERMIT � �' I here6y alfirm thai I hqve a certificate of consent to sel( ��s�.e,or a tertificale oi Workers Compensaron�nsurance, j6A3aac HEATING - VENTILATING - AIR CONDITIONING or a certified,opy thereaf(Sec.3800,Lab.C.) - p P y Q���Z�L CE-B18(R(V.10/81) ' :. .. �.. - ... . . , P❑olky hlo�¢.,Com an— . . . . . Certifed copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY � Ce�tified copy is filed with the county building inspeo- FOR APPLICANT TO FILL IN: BuitD�NG f B 7 �r��'�O� fion deportmenf. ADDRE55 2� � (PRINT OR TVPE ONLV) /� ��//► /���� Da1e!��..Applicani �. LOCALIN L/! ��J6�✓f� .�T�� NO. TYPE OF APPLIANCE OR EQUIPMENT FEE � CERTIFICATE OF EXEMPTION FROM WORKERS' NEnkE57 � . COMPENSATION INSURANCE . CRO55 ST. (Thl�tsc n nwd nof ba comple}ed if fhe w nvolved by Ag50RPilON UNIT,BTU 01S1RIC(NO. VRp[ESSE�D BYIr tha permit for one hundred dollars(S or loss.)� q�R HANDtING UNIT,CFM ,2 j'�{} ' � I certify that i e performanee of e work for which rhis �y permit is is5�ed,I all not empl any persan in ony manner � so as�o become su6i �to� orkers'Compensation Laws._ 90RFR,BTU ' pv7aovnl5 �ATE MSPECiOR'S SIGNATIIRE _ Ddta - PP��� � COMPRESSOR,BTU ROUGH S":���_ Z_ NOTICE TO APP ANT: If, afle- aking Ihis Cerfifi�ale of VENTIIATION SYSTEM FINAL (/�` Exemplion, u shoold betome bject to rhe Workers' � Compen ion provisions of the labor e,you must forth• �yqppRqTive Cootea � VALIDATION with mply with such provisions or � permif shall be � � d ed revoked. . � FURNACE: FAU—GRAVITV - -" � � IICENSED CONTRACTORS DECLARATIO FLOOR BTU � I hereby aHirm ihat I am licensed onder provisions of Chapter 9 SUSPENDED - - UNIT_ � -� � - . '(commencing with Section 7000)oi Division 3 af fhe Business HEATER: WA�� - , and Profe:sions Code,and my license is in fvll force ond eifect. -�-� - � - � -� -� - - i�y„ . �" � .J�J a � ����} O _ .Litense Number�d�.���Lia ClassS,t=v'�. - � � - - � - � -� �� , _ V . �w �b701A o Conlractor T�f�/�1�Dote 4�z4/a� - . .,_ . . . . , , . . I am e.empt under Sec � __ . � • •.''•c� w � Plan cfieck fee - _ a � • •7QOO � BP.C.for rhis reason oa'e. pERM1T ISSUING FEE S O Q .� � ' z ' TOTAL FEE ' • ' �0 0 0� _ � $igna e ��1,z,Q—8 7 WNER-BUILDER DECLARATION � PLAN CHECK AVPUCAnIT . � . I hereby affirm th I am ezempt from the Contratl s License , , . Law for ihe follow reason(Settion 7031.5, usiness and NAME . � ' . . � Pro(essions Code): � � . � ADDRESS � ❑ I, as owner of th property, or employees with � woges as their sola mpensatio will do the work and -� the shuctu�e is no�int ded offered for sale(Setlion CiiY TEL NO. 7044,Bosiness ond Pro s" ns Code). � � ��� ' OWNER p ,��G �(/�C��r� O TI � ❑ I,as owner of�h'e p�o rt am exdusively toMrac�ing � with IicensCd contr ors�o nstrud the projeU(Sec- ��� �� - - , � tion 70d4,Busine and Profes� ns Code). ADDRE55 G/f� L � CONST TION LENDIN GENCY �in G rei.No.- �� � - -� � I hereby affirm th here is a constructio lending agency for - lhe performant of fhe work for which th permit Is issved CONTRA�TOR µ� � -- ---- ` ' � � (Sec.3097,C' .C.). � - _ .. . . . .._. . _ . . - � � ADDRESS I V- ES�r �. . . . . . _. . � . _ . .._ . Lender' ame � - CIN � TEL.NO.� . . _ _._ __ . _, _ � le er's Address ' �. ' I certif that I have reod this a lication and state that the. SiniE uC. . Y PP LICENSE NO. O - .... CLHSS �'. ._. ._ .. ._. .. . above informotion is correct.I agree to comply with all Coonry � �� � ordinances and Stoie laws relating to building tonstrvttion, � � , . _. .... . _ ... . - - ' and hereby au�horize representaiives o(this Coon�y to enter - �� -� � ���-� � -- �-- � - �apon the abooe-mentioned property for inspettion purposes. SEE REVERSE fOR EXPLANATORY LANGUAGE _ Sign�+ure of A mont or Agenr � Daie � � -� � ' � �� - . - �_--- . . _..--�"�� "' � • _�- �t '�,; � , ,- �` , t + j � � � ' ��� ' ��1 �?� . 11_ ` '�� . 3 '� %,,� . � - ''� ��. tVdl" '� \ �._' - •, �'` � . ' � � _ �`� . � �_. ��` ��y' �%'�' .,r , ' • ti : ` Y '�! • �� `jf, , . . r ' � ' t � , tr� � : � z ���.; . '• . , � . «_.. r y •r { ' �_";, ' 1� ; "r. �11 � � - . ����� . �%� �'.�� . - � � � � � ',� .- ' �� �.� �� . .. ,, . ' �.p . . . ;� 1 � /�. �J\��, . ., .,- . O . ` 1 , y .. ,• , � 7� 4 , , vf • ' - � p{ `i ' '; v� , '• , � j� � ,—:. �`� ' ��' .. _ _ - �; . �- � ' c�.' - - , 11 �'4 `i�� . � �rt'.� .. . �l y .4 F � � d.. r '•�' - i 1 ` `',\ u .- '� � ., � ;� . -a � t � n , ;� � � � � �, , � , r� 1 � � ;.� rir, ,Y �i� . �` � rS '� . ' � , a � � 1. _ A. '("1, �\ ' �� � � ., p� �� '� � -, r �� i � , �1 �� '\ � . ' �\. � , � � � '�� � . , � i* r,� �� ,�, /' � � �^, ; � tt• , , � t�l, t'. - � �• ,(/ kr ��', t�'�' � ,�t � .�' ,� ,� .�? ��-�, ; � �j• � i ,� '; �\ �fi j' ,r'1 ,(�' v �:t � , � . - � �r,� 'r• �✓ �w �i �. �✓: . .� - . � , � � ��.� ' � , 4.- - ' � : •� ` ` ,� � i :`� f t. i vr i•.v ,'S� i lt it , ti � • � ' �I/ �, . � 2': . L; . - �i �r �� ., � ��� �''y � ''i �,( �, �f ,'y, '_ �' '', �r�% � ' (t. ��„i. , r t'1, . . , , , t .�j O 10 N p � r tr` E r. • r. '�' ',i• J _. ,�'�n?n� � c � N m. r '� '�,' -� ' � ', � � oo`on�y�,M'..'°om `° c+ ,�c. '! S O 7 i v p Q S�p�" �q 0:. � ,� � . � 4� ^` � � o m � o ,v�W n� �.a p ° � f �1 Z l � � 1 � ` F�Sr'-,^� o,`t'4�F� � on(?ina� �n oN ��� 3 o ��n �� LT 1� U . j' ,� `� �, � p�� �1 / tT,m,,O d``S C N �'-0„� p O.'+ 7 � O^ �n �..ri;' � N ?p �, . ��. ' � �=,o u���._(�� Q�m n.'3ti�H �m a o<."'c ��.��� �i� 'p:� m ,,. �- ' � � �O p,� � ^� f� o a„�° `�ro � � �'.. �;e�� o p ° Q o�? ? a� ',Q - � .w . ..o� � �x-3' ' 1 Q �j� ,R �0°_`7"E% .s°� " ,� Pv �'N O � Q,p � .Q ofl ��� -- o� X ?a"' ; p o 0 0 � 3 o3a o �aH � f � � � a� Ww�f� _ n ' � . i� � 'n� K� � �,N o Q N m°� 'o f o a�:m.o�� '�� '6'� w n;�°�o� e,o �, :� �� � �� ' �' 1� � °.� c � a N < �o..o w ° ""n.am�! Q� c, �..�Q m o ' a�°� '� � i o 'c? � 3 a.N � m a ¢w o -o �v .n ' � 3 .°� � o -� a .�; �,,� _ �� j :;s'° o o.� q� N N �_a- r o ° 'L3 T � `�.e o � /� T � � , ^ Q � �::f�� n.,�. ° �-a�,�s o p o-°��� � c, ° 'o�.'r' _. � �.':�p ' •r . � �. (. . N N N �.N 7�Q,.'f �� 3 1� N ��.N �n O K-� m ,p�I� u 3"„G ,�,�,'� i . . � _ .. � . p D O�'O �� t0 Cf O 'r.G t0 K Q..r..G �`< l0 N W �~�^ ° 0 !0`• �Q . . ^ '.. '.1 , J �D' � � n C � � � . � p N� a.-'� pvp d° � �m �.3'� ° ,a� f � N o 0 0 'fl ��� o ... ` � � O � ' `c✓°ro='N °'�7v �wf3�a °�•.oq ' a�:�'3_N3� N m =° >>� 'Z . � ` . 1 � . � , o �.t M �� N w� �.� a�}'��� ���-�:'a,`��.o u�r- �,� ,,,,�o JI � �p a�i,�n Q p�'� �p m f�.�'.Q S �C '� 0.�'p-�N O'N p'� W p ��. �•.,,^ �'� �'p.� c� N 3 N o a�3.� oi���.o,f a a v+�ro �o�a °.fl� N� ir N \ ' . / ,\ �� (-� ���`a° `n �o�va�2.o.on. °^F �'°v^.a��-mW� �'?- e��f`- . .. � ' /-' � _ p,n -• S .•~ S h - pf� O?�. � m`-j `w � . . r -. � . . . .�O pN q ? c ' f?O Q'r, .V,��^n - 7 O. ' /''� l \ � , .� v � � ��� , �� ��� � � � a. ��� U' / � . o,,°..o �o n c�s1� o �r i+.�/• . - . ro. o o„° " _ . .. . ' . �'.N l9` d n 7 . ��. . . . . , ' . .. . " ' n O .t r � � . . . . � �. O . � �/ - � � ' , . �` • . . r �..���. .� �., `y. ' : S. - � �✓'j . � �:':. �. � ,_ �.. - - .� :`' 1���� ` ,'. � � v�_ (�,!