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HomeMy WebLinkAbout11_16_1984 - 21073 PATHFINDER RD- Compressor (2) WORKERS'COMPENSATION DECLARATION reby affirm Iho}I have a certificate of consent to se�f APPLICATION FOR PERMIT �' sore,or o certifkate of Workers'Compensa�ion i�:��a��e, ,bA3aac HEATING =-VENTICATING - AIR CONDITIONING � or o certified copy thereof(Sec.3800,Lab.C.) . �� ��a_�.,r CE-818(REV.ID/81�. : � .. . . . ..-- P❑olity N ampany !vJ . . . . . . . '- Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY � Cer�ifled copy is filed with the county building inspeo- FOR APPUCANT TO FILL IN sui�oiNG /� 07�j � �. tion departmeM. ADDRESS f �J ��jFIN /��f �PRINT OR TYPE ONLYJ Date �/�JG�r'�'1+pPlicanl ��-����Yfl� . LOCALITV ��yyt.p� � - - NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' - NenaeSr � � COMPENSATION MSURANCE � . CRO55 ST. 9 �� � (Thl�seclton naad not be complatad if iha work tnvolvod by AgSORPTiON UNIT,BTU oisrxia r+o. Px ess ar �ffi�permif b for on�hundred doilars(5100)or lese.) � � riify fhot in fhe performante of the work for which this A�R HANDLING UNIT,CFM � �`per ' is issued,I sholl not employ any person in any monner - � - so as to tome subject�o ihe Workers'Compensatlo s. ., BDiIER,BTU nvvaovnts onrt INSPFCTpR'S SIGNATURE _ �J COMPRESSOR.BTU VN/J G iavM �D DD ROUGH � Da�e pplitant NOTICE TO APPLICA • er making fhis Certiiitaie of .� VENtiIATiON Sv57El�n � �/ FINAL � _ Ezemption, yau ecome subjett to the Workers' - Compensati rovis�ons o La6or Code,you musl forth- EVqpORA71VE COOLER VALIDATION � with p y with s�ch provlsi or ihis permit shall be , med revaked.� � . � FURNACE: FAU_GRAVITV . . �LICENSED COMRACTORS DECL TION FlOOR otU . - I heieby affirm that I am litensed under provisio of Chapter 9� HEATER: � SUSaENDED UNIT_ -- � . �(commencing with Sedion 7000)of Division 3 of t Bosiness � WALL . � end Professions Code,ond my license is in full(orce on fect. �"' /0 2 Zi / n�Tfcnro�.. -�'s►--'� !nvru�]-- r2 b0 a _ License Nomber �-� Lic.Class �%� ��-'W� ���,� . . - l� . .�� � . � _- � �r..�.��.� OC CoM tor (`r�il tAJQ Dote.!�^l6� .�'7!� � . . . _ .. _ . � � QF . ❑ �am �xempt under Sec. . ;_�G`j Q U{� w 8.8P.C. this reason- � P�an tfietk fee� �/ ' . n. Date: PERMIT ISSUING FEE 0 . �� � �?2 z Sgnmure TOTAL PEE I • •6 3.?_5 -- . OWNER-B DER DECLARATION PIAN CHECK APPUCANT '����ah����+ � � �'e 1J a 2 j? � I hereby affirm ihat I am exe pt from ihe Conir or's License - - ' Law(or Ihe following reason Section 7031. ,Business ond NAME n��,�, � . � � � � I�1.1 b—8 4 � Proiessions Code): � ❑ I, as owner of the properl or y employees wiih ADDRE55��3� ������ :,r��Q O� � � ' wages as fheir sole compensmi ,will do the work and p�± w,w /1r� �,�. the structure is not iMended o ered for zole(Secrian ��rr]•/C' `�NT�' � h�' 'u!J �7J'N�7� t.�• . • •8 � 7044,Business and Profes' ns Co ). � � � � � -� - �� . �' - � � ❑ - - . OWNE O � f�� I,as owner oi the pro ily,om exdu'vely coMraUing � ��'��G � • 1 3 7.�0 � with licensed mMr to�s to tonstrod t ro'eU Seo- �`�� /-� �"`� � � p � ( ADDRE55 �f Q 2 � V7C�qf.+�(. �LO = � tian 7044,8usine and Professions Code � - � . e � z 7.��� CONST TION LENDING AGENCY �� Ciiv ,��N� - �� 7EL�v0 7 ppp . �, . � �hereby affirm th ere is a constrvU�on lend�ng a ncy for ' I �,�1 6—8 4 the performanc of the wo�k for which this permit is soed COMRACTOR�� ��VAI�fJ - � � (Sec.3097, ' .C.). - � . �( _ - -.. _._.... .. _...._... ... - � � ADDRESS / t"� a7�,�{fA J�4/� . .-__. ._. . .. , ..;�. . : ' . � lender' ame ��x � , � CITV � Mo�,� ..TEL.N .� Z�lil"�.]T7 I . .. . . . -. Le der's Address n/J�r �y � . � � -"� I cerfify that 1 have read this application and sta�e ihot the. LICENSE NO. �G'G(/��J - CUL55� �.yO� . . ......_. ______ __.__.._. .__. _ above informa�ion is correct.I agree�o tomply with ali Couny � - � � � � �- -� ordinaaces ond State laws relating to building conetrodion, _ _ � � and hereby outhorize represen�atives o(this Goonty lo enter . - �� - - "'��" - � �" '�� �""� - �- �-�- � upon ihe obove•me ioned properiy for inspection purposes. _ �SEE REVERSE FOR EXPLANATORY LANGUAGE� ll-C�o` g� � � . . -- - - -- - � - - . . .. . • . ... .. .__ . _ _. ... . _.._ . . .. .... .. ._. _ ..— � -- --- Sig�orure of ApplimM or AqeM � Do�e - � . � .--.. :` � � �� � ',�� ` �� ,- �, � ' '�� ';��.' ���'� . • ,� �; �•' ~ �'�1 .,f '.,;''" \ � :i .', ' � ti '�4 , , n . '� 1'�� `.�': �, t r ` ,', - �I ./ C �.. 1 , , r ' � ' , r . � �{ ��� .. i � � ' - � �� �" � � �° � ��� � � . ���. ._ , �. - . ��,. • � � .. . , , q , � yl' '� � ; „ - � ,_ �'� 1 � � ... Z 4:� � '� ,`N: . � � ' +y � .. . .. ', 0 . �i , '70 , , . N � ' ;- ; K � � � . , �, � � � � . 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