HomeMy WebLinkAbout1_11_1983 - 2016 PEACEFULL HILLS RD , i
11'ORKERS'COtitPENSATfONDICLARATION 76A364p � APPLICATIOftiI FOR I'ERi�91T � � �
I herehy afCrm that I hare a rer�iCcate of coment to self CE-876(2801
insure,oracertificateofworkers'Compensationlnturanre,oi HEATING•VENTILATING-AIR CONDITIONING
a certified copy ihereof(5ec.3800,Lab.CJ '
Policy t�rn. $06-82 Cnmpany�e Comg_ rns. Fund
� ❑ Certiiied copy is hereby turnis6ed. COUNTY OF LOS ANGELES Bl11LDING AND SAFETY
Tr. 1�32576 Lot 43
� Certi(ied copy is flled with�the county building tnspection BUI LDING
iieppa�r�tm�e��t.� FORAPPLICANTTOFILLIN
Date L!1_1r u� Applicant 511T1711j.t �S18EL 1f2tR�. (PHINT OR TYPE ONLY) ADDRESS 2016 Peaceful Hills RCl.�
� LOCALITY . W�L
CGR7lFICATE OF EXE\fPTION FROTt\VORKfiRS' , NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CO?1PENSATION INSUI2ANCC NEAREST �J
(Thls Section ne0d OOt b¢COm�leted if fh0 n'o�k invOlved ABSORPTION UNIT,BTU CROSS ST. ;�j�/�j��/v�JL.�/l. O
by Ihe permit is for one�hundred dollacs (5100)or IC55.� . DISTRICTNO. PROCESSEDBY
I certif�Ihat in�he � v
y perFormance oC ihe work inr�vhich this AIR HANDLING UNIT,CFM i7 �
permit is issued,1 shall nnt employ any person in any manner vj O
so as to become subject tn[he lYnrkers'CumpenSallon Laws. BOILER,�TU f-
' ' � APPROVALS DATE INSVECTOA'SSIeiATUaE U
t)ate � Applican[ � � a
COMPRESSOR,OTU ROUGH f �
NC �TO.4PPI.ICANT:ff,af�er making this Certilicate nf Z VENTILATION SVSTEM LZ OO FINAI ' _� Z
lixc,..�tion, yoll should become suhject to the 1Vorkere' —
Campensation pravisions of Ihe Labor Codr,you must furth• � '
�vith comply wi�h such provisions or this permit'shal! be EVAPORATIVECOOLER VALIDATION� '
deemed revnked.
� � FURNACE: -FAU_GRAVI7V .
I.ICENSED CONTRACTORS DP:CLARATION F�OOR� �TU
1 hereby affirm that 1 am Iicensed under prucisions ofChapter HEATER: SUSPENDED UNIT
9 (commencing with Stction 7000)of Divisinn 3 of the IIusi� WAIL
ness and J'rofespons CoJe,and my license is in full force and
effect. '
License Num6er 195932 LIC.(;IJ55 C-43 �
Cnn�ractor Sttr+mit_ Dare 1/11�83
O [am ezempt from ihe licensing reyuiremenis as 1 am a ��� � -��z 9�,P
ticensed architect or a regietered vrofessianal engineer plan check fee 25°'o of above. �� � �,� ��
acting in my profession�l cap�city (Section 7051, lSus-
iness and Professions Code). , PERMIT ISSUING FEE S 1� .5� � e '
'�G Q.- `
G�ll' �\
I.ic.or Reg.Nn. Dat� TOTAL FEE 2Z $p 0'��� 3—i:j�
� IiORiC D\VNGR-HUILDER DECLARATION PLAN CHECK APPLICANT
i hereby affirm ihat I am exempt frnm-the Contractnr's NAME Su�.it Sh . Tr Q.� Tn .
U^^ se Law fur the following resson (Section 7031.5, �usi- �'
. --. .__ ...._ . _..
r narroress;onsc�,ez): nooaess 21511 Selshire St.
Cf 1, as o�rner nf the prnperty.�vill do the work and the CITY TEI.NO.
Stracture is not intended or offered for sale (Sedion HdD:Zf�3R -3 CI ?7-R
9044,Business and Vrofet5ion5 Code).
❑ OWNER tf, J. IIrocI: & Sons Inc. �
1,as owner of the'property,am exclusively contracting
with licensed contractors to cons[ruct the project MAIL
(Section'l044,Business and P�n(r5sions Code). '� ADDRESS 1648 Greenhri2r Laae ;"224
CONSTRUCTfON LLNDINC AGENCY CITV $rpa TEL.NO.SZ9-SL]O
I hereby a((irm that there is a cunstruction lendi�g agency
f��r ���¢ performance �f the ��•ofk for �t�hi[h [hi5 petnlit is CONTHACTOR S fi','pta]_ CO. I17C � � - '
issued(Sec.3091,Civ.C.). � � . . - -
Lender'sName ADDRF55 ZZg11 Belshire St. -
Lender'sAddresi ��T� FT��aaiian Gardens rE�."o. 5Z7—E�6 � � � � - �
1 cerfify fha[I have read Ihis applicatiun snd 5tate[ha[ Ihe
above i�fninlation i5 COrreCt.1 agree to comply�vith all CUUnty LICF.NSE NO. 195�32 C ASS C-�}3
ordinontts snd State la���s regulating Heating,Ventila[ing and �
Air Conditioning,and hereby authari�e representatives of this SF,E RFVERSF,POR GXPLANATORY LANCUACE �
County to enter upon Ihr abure�mentioned pruperty fur - � � � -
ins>ecY n purposes. ��� J
(` l.CW� 1�i1�s3
�nature of Yer ittee pite .
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