HomeMy WebLinkAbout01_11_1983 - 2016 PEACEFUL HILLS RD , i
11'ORKERS'COtitPENSATfONDlC4ARAT10N 76A364p � APPLICATIOftiI FOR I'ERi�91T � �
CE-87 B(2�801
I herehy afCrm that I ha�'e a rer�iCcate of coment to self �
insure,oracertificateof�t'orkers'Compensationlnturanca,oi HEATING•VENTILATING-AIR CONDITIONING
a cerQfied coPY ihereof(5ec.3800,Lab.CJ �
roi�oy rr�. 306-82 comv3�s,���omg_ rns. Fund
� � Certitied copv isherchy turnlshed. COUNTY OF LOS ANGELES Bl11LDWG AND SAFETY
Tr. 1�32576 Lot 43
� Ceetitied copy is f[led with�the c�unty 6uilding inspectian FOR APPLICANT TO FILL�IN BUILDiNG
�e ,�,me t. ADDRESS Z416 Peaceful Hills Rd.
na�r 111�'R Applicant Surmtit �heet t'etal (PHINT OR TYPE ONLY) /��
LOCALITY . LU/TL
CCR7lFICATE OF EXE\fPTION FROrt\VORKLRS' , NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
C0�IPENSnTiON INSUI2ANCC NEAREST n�J r /� .y �
CROSS ST. ;f'p��j—�/�/Jf' �
(This section need not be eompleted if the nnrk im�olved ABSORPTION UNIT,BTU vaocesseoev O
by the permit is tor one�hundred dollacs (5100)m IC55.� . DISTRIMNO. ,.,f��"
I cer[ify Ihat in�he perFormance oC ihe����rk inr�vhich this AIR HANDL�NG UNIT,CFR1 � �"" O _
permit is issued,1 shall nnt employ any person in any manner
so as to become subject tn the lVnrkers'Cumpensallon La�vs. BOILER,�TU qppROVALS DA7E INSVECTOA'SS��+aruae W
a
I)ate � Applican[ COMPRESSOR,OTU ROUGH _ f z
NC �TO.4PPI.ICANT:lf,aiter making this Certificaie nf Z VENTILATION SYSTEM LZ OO FINAI � _� —
lixc,..�tion, Yov should become suhject to the 1Vorkere'
C�mpensalion pravisions ot tfie Labor Code,you must tucth• � EVAPORATIVE COOLER VALIDATION�
�vith comply with such provisions or this permit'shal! be
deemedrevnked. � � FURNACE: -FAU—GRAVI7Y
I.ICENSED CONTRACTORS Dl�:CLARATION Ft,00R� oTU
1 hereby affirm that 1 am�icensed under prucisions ofChaPter HEATER: SUSPENDED UNIT .
9 (commencing with Stction 7000)of Divisinn 3 of the IIusi� WA��
ness snd J'rofespons CoJe.and my license is in full force and
efPect. '
License Num6er 195932 LIC.CIJ55 C-43 � .
Cnn�ractor Su��_ Dare 1�11�83
O [am ezempt fr�m ihe licensing reyuiremenis as 1 am a ���G 9,�i P
ficensed architect or a teRietered professianal engineer plan check fee 25°o of above. #• • •'� �� {�
acting in my professional capecity (Section 7051, lSus- pERMIT ISSUING FEE$ 1� .5Q � ° '2 G y��; J
iness and Professions Code). . �G„„;., �-
I.ic.or lieg.No. Dat� TO7AL FEE 22 5Q 0`��� 3—8%
� NOT.iC D\VNGR-Bll1LDER DECLARATION PLAN CHECK APPUCANT
i ha�eby afticm thst I am exempt from-the Contraclo*'s t�7AME Su�.it Sh . ?* Q�_,�7n -
U^^ se Law fur the following resson (Section 7031.5, �usi- � _ . _.._- � � --- - - - - - --- � � � � -
r �narroress;onsc�,ez7. nooaess Z1S11 Selshire St.
� 1, as o�rner nf the property.will do the work and the CITY TEL,NO.
Stracture is nol intCnded �c oCtered f�t sale (Section {;g�qg�i3i1 -3 GI Z7�i
9044,Businessand Vrofet5ion5 Code). OWNER
� 1,as owner oS tfie'property.�m extfusivefy contiading Zf• J. nroeI: � SOriS 7RC.
with licensed contractors to cons[ruct the project �"�A�� 1648 Greenhrier Lane in22�s
(Section 1044,Pusiness and P�n(rssions Code). '� ADDRESS
CONSTRUCTfON LLNDINC AGENCY C�T� �YP_3 TEL.NO.52(�—S1]O
I hereby uffirm that there is a cunstruction lendipg agency CONTHACTOR � �
far �he performance of the �oork for which this permit is $ �`��Ptal CO. I17C . - -
iesued(Sec.3097,Civ.C.). -
Lender'sName ADDRF55 ZZg11 Belshire St.
[.ender's AdSresn ��T� FT�waiian Gardens 7�L."o. 5Z7_EII6 � � � � �
1 cerfify tha[I have read this appiicatiun�nd state that �he STATE 195932 ���' C—�+3 .
above i�fninlation i5 COrreCt.1 9gree to comply�vith all CUUnty LICF.NSE NO. CLASS
ordinontts snd State la���s regulating Heating,Ventila[ing and .
Air Conditioning,and hereby svthorire rep*eseneaSives of this SF,b RF\�ERSF,POR F•AYLANATOitY LANGUAGE - . � -
County ro enter upon Ihr abui'c�mantioned pruperty fur -
ins>ecY n purposes. . . .
CI�, , � 1/ii/ss
.. nature�Yerfiittee Date . - . . . . . . .� . . -. .. - . . ..
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