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09_19_1985 - 21015 PATHFINDER RD
ERS'COMPENSATIONDECIARAT10N APPLICATION F,OR �PERMIT � �Ihat I hava a tertiticate of consent t�s f,� ' � . rtificote of Workers'CompensaliOn Insurh�+Ee, �bA36ac. ��' .. . . ' HEATING- - VENTILATING -�AIR CONDITIONING � � :opy rhereof(Sec.3800,lab.C.) � �-� ��,��,� ,1 ce-ei e�eev.i oiai� p��or.s LLZ'-'�Company IV A'h�6N����L. _ . .. . . . . . o��.g d copy is here6y furnished. - . COUNTY OF LOS ANGELES 9UILDING AND SAFETY "�h��h :d topy is filed with the coonry boilding inspeo- - FOR APPLICANT TO FILL IN - � euitoiNG o%s�, npartment. . � � , aooaEss �1� o�o �p �� `� . (PRIM OR NPE ONLY) r� p 1ote. �-1=t SApp�icant��-a 1 f�?'�%�!c� � LOCALITY .R7 tV r�he '. NO. NPE OF APPUANCE OR EOUIPMEM.' FEE RTIfICATE OF EXEMPTION FROM WORKERS' - NEnREST � "'��� COMPENSATION INSURANCE . CRO55 Si. �-� � �es- � ABSORPTION UNIT,BTU DIStRICI NO. PR ESSED Y lon n��d not b�compls�ed iF Iho work involvad by � '�'�s It i�for one hondred dollnr�(5100)or loss,) � ��0� Ihof in Ihe performonce of the work for whi[h lhis AIR HANDLING UNIT,CFM -� . _ P��- issued,�l shail not employany person In any manner red� become subject to ihe Workers'Compensation laws. BOILER,BTU APPROVALS ' �ATE INSFECTOR'SSIGNAiUQE — nd • APPlimnf . COMPRESSOR,BTU �n�.FQnry � p U� ROUGH � :To AaPIICANT: If. afrer makinq ihis Cer�ifica�e of 5 vFNnunont�s+r5x� �NS � � FINAL �p�z� �� � vc. ��ion, you should become subjed ro the Workers' . . �/Y ensafion provisions of the lobor Code,you murt fodh- EVAPORAiIVE COOLER � 0 VALIDATION �h comply with s�ch provisions or ihis�permit shall be - � o� �ed revoked. � � � FURNACE: FAU_GRAVITY - � �� � � or LICENSED CONTRACTORS DECIARATION � . . FtOOR BTU , e �eby affirm ihat I am litensed onder provisions of Chopter 9 SUSPENDED UNIT_ , HEATER: WAtL /d nmencin9 with Sedion 7000)of Division 3 of�he Bosness . ��8 2,9�i � � �1 Professions Code,and my license is in full force and effecL � - � - _ . � y #e . . . .8 � � .ense Number �7��S�1 Lia Class� �r � / y� 'n�� -D , � - � � � I •341.50 Q ontroctor�Unl'llf�j�C�Date.9—I���S - � . e�4 �.SG�� �J � I am exempl onder Sea , _ _ _ _ . .. � W � Plan check fee a:aP.c:ro.,h�5.easa� 0 9,1 9—8 5 Z PERMIT ISSUING FEE s O a Dote: Signmura' TOTAL FEE y� - � OWNER-BUILDER DECLARATION � ttAN CHECK APPLICnNT ' ' I hereby affirm ihot I am ezempt from the Coniretior's License , Law for the following reason(Section 7031.5,Business ond NAME � � ' Professions Code): � � - - � � , ❑ �; as owner of 1he properfy, or my employees wifh ADDRE55 ' � wa9es os their sole compensation,will do the work and - . -the strotlure is not inlended or offered for sale(Sedion CITY TEL NO. 7044,Business and Professions Code). . �- • � - - � - � �, OWNER � . . ❑ I,as owner of�he praperty,am ezcl�sively tontracling wilh licensed mNracmrs to conslrotl the projetl(Sec- �"u`�� -��� -�� � tion 7044,Business and Professions Code). � , ADDRESS (� CONSTRUCTION IENDING AGENCY CiTY`�� - . - � -tEC NO. - -� -- � ��- - I hereby affirm thot ihere is a constroction lending agency for - , - the performante of ihe work fo�which this permil is issued � �pNTRACTOR �-- �� � ' (Sec 3097,Civ.C.). . . . �p � - ' ' - . -. . . - . . . .. . , - ADDRESS 21 at� E= _. . . . .... .__- __ _. _ . __ •.- ., .. __. . . � Lender's Name � � � ' CITY.. //b� ._ TEL.NO. ��Z � . _ . . _ __. _. � . .. _ _ . lender's Address STATE UG �certify that I have read this application and slate 1hoP the LICENSE NO.�3S �J�-- - -C1A55���� � � �---� � � � above informa�lon is correct.I agree to comply with all County . � - � ordinmces and Stale aws relatin9 to boilding consfruUion, . � . and '�reby th 'e epresentatives of ihis County to enler � � � � ' �� - -.���� �. � � --� �� � �� ��� � � upon e i ned property for Insped�on purposes. 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