HomeMy WebLinkAbout1532A __...,,.,�.n.uecL4RAT10N qpp«CATION FQR PERMIT �
r heraby affirm lhaf I have o certifico�e of consent to self
insure,or o cc+"ificare of Workgri Compensation InsUmn<e, �bA�4C HEATING - VEMTILATING - AIR CONDITIONING
or a cerlified copy hereof(Sec.3800,Lab.C.)
CE-818(REV.10/8I)
-�Policy No. Company COUN7Y Oi LOS ANGElES BUILDING ANO SAFETY
�CerYified copy is hereby furnished.
� Cenitied mpy is filed with fhe coamy building inspeo FOR APPLICANT TD FILL IN aUuoiNG �jZ,;.r _/ S �y'/��r ne
fion depaftm¢nt (PRINT OR 7YPE ONLY� A�DRE55 G y i�-t /�/4�
�ate Applicanf tOCAl17Y �'" J/�
NO. TYPE OF ACPLIANCE OR E�UIPMENT FEE �^
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST �j �� C�
COMPENSATION INSURANCE CRO5557. /!(
� (Tht�s�cfton nNd nof b�eompl�t�d i(�hQ work invelvsd by ABSOR7TION UNIi,BiLI DiSiR�Cr rvo. PROCE55Eo eY
fhe parmif L for ons hundrad doilars(fiOQ)or leas.) qIR HANDLING UNIT,CFM `�` �
I certify that in the pehormonce of the wark for which ihis �O ♦�`
pe�mif is issued,1 shall not emplay ony person in ony manner gOILER,&TU
so os�a become so6ject to the Workeis'Campensa�ion Laws. nvveovnts onre iNSPccroa�s si�Nnruae
Dote �� pplican � COMPRESSOR,BTU ROUGH _.,,,
NOTI 7 APPLICANT: If, of e moking ihis Cenificafe of vENTILATiON SYSTEM FlNnL �
Fxemption, you should beco e subject to fhe Workers'
i
Compenspiion provisions of�he labar tode,you musl farth- EVAPORA7NE COO�ER VAUDA ION
with comply with such provisions or fhis permil shall be
deemet�revoked. Fl1RNACE: fAU_GRAVITY
LICENSED CONTRACTORS DECLARATION F�OOk aTu
I hereby affirm+hat I am licensed under provisions of Chaprer 9 HEAiER: susveNOEo uNii�
�(mmmencing with Section 7000)of Division 3 of 7he Business l'✓!«
and Professions Code,and my license is in full force ond effe<f. � �
0
ticense N�mber Lia Class � O , �
Confractor Date �
❑ I am exempt under Sec. �
Plan check fee N
e.xP.c.far this�easo� pERM1T ISSUING PEE S \O �'
Date:
5ignar�re TOTA!FEE
OWNER-BUILDER DECLARATION PinN cHecK avvucaNi
I hereby affirm Ihai I om exempr from fhe Coniracror's Li<ense ► �
Law iar fhe following reason(Secfion 703I.5,Bus�ness and NAME
PLoPessions Code):
f'Tit AD�RE55 v J
JfU I, as owner of ihe property, or my employees with �7 �-G i�4
/ agee as�heir sole campenw�ion,will do rhe work and CiTY ieL NO.
the slructure ia not intended or offered for sale(SeUion {�• e a s ,�
7044,Business and Proiessions Code). �
OWNER � �/e- � I • •C[
❑ �,os awner of fhe property,am ezdusively con}rading ��-�
wifh licensed controdors b co�srruct Ihe project(Seo- MAit �7 �`r J
ADDRESS�(... /c-/� /C. .�:
fion 7044,Business ond Profession Code). ' ° ��- �- "
CONSiRUCTION LENDING AGENCY arv�� ���j ��� ret.No.�� �3r•3� �,C .y �-;-_4,,
I hereby affirm thar�here is a consirucrion lendi�g age�cy for d • -
the pertormanre of�he work for which this permit is issued CON7RAC70R Q��Pje.' ,
(Sec.3097,Civ.C.). ��� �
��A�_lyi ADDRE55 (� ��J ��
Lender's Name �i�"�����--
Lender'S Add es CITY ` �✓ � TEL.NO.� _ 3�
STATE IIC.
I certify thal I have read this opplicafion and slate thaf the IICENSE NO. CLA55 �
above information is orred.I ogree fo comply with all Cou�ry
ordinances and Stofe lows relating to building construc�ian,
and hereby outhorize rep�esen�atives of�his Counfy�o enter
upon thNa�se-m ned prap�for i���p�oses. SEE REVERSE FpR E7CPLANATpRY LANGUAGE
'�yL d
.gnoture of Applicant or Agen+ Dote
R Pif3 C7Ye1d�R-AUflb@R CifCLAA�471CAL
. I hereby oti�rm ihor I a .Pmpt from the Cnntracior's
censo Law for rhF {o�loaing r ., n (Ssction 903L5,
6usiness and Frofns=ions Coda)-F,ny�.ay or county vihich
� � - ^ requires o p^rmll m mn>fru:t altcr,irnpro�c,dnmol;sh,
. T repatr ony sfructurc,prior to i�,issucnce, olso rc-
. � qulres N-ee cpplimn�for sud�permif to file a signe�d s�ate-
� , enf f6of he is licensed pursucnt to thr,provisions of�he
� ' �'- '- �'� Confroctors License Law(CheHf��r 9(commenciny wirh
_ecfion 70�8)vr Divi.slon 3 of fhe 2�siness vnd Pro?es-
sions Code)or 7hct ha fs exa��n�i 7herefrcm ond the hasls
� - for the cltec,ed e vnpNen. /�ny vPolatian of Sec�ion
� 7�31.5 by ony applimnt for o psrmil xuF.;ects the a�p,'i-
ant to a ivif pancLy ef not moro ihcn five hundred
, � doilars(bsOC).:
._I,c�c�w.o-w of�he prop�rty w��ll do the��ork,a�d
,. � — � �he strucrur�i not intendad or oficrod for sdl�
� (Sec 70.-0,Bzrsiness oad frof;rslons Cod.�: 7he Contrac-
� for's Licen<i•Law daes nnt c�ly to an ewnar o4 prope:ty
�-�4a bu�ids c ir�yzrov�=: tFe+�rn, ond wha doex sueh
� "�� i� �Nor6 hirrse7J provic.'cd 7har such imprv. n_n;s a icr
i.�tcnded or oHa-ed for s�le.lt,hcwsv_r,iRc butidrn�or
�� '�� ' impro�emenf is s»id within ene y��er of<ompfeli,n.f6e
owr+er-bui7�«r will he�d+a�urdc-n cl pmving�no�h�did
� . nai bvild or imprcv��or th�purposc of sole.)
. . ❑I.as oWncr o41hc ProP.'rly,a .xclusiv'rly c.
o-acting vilih licensed co,rrflcicrs'o o. .��i!ti��.���en
� (Se�c.704�.1�usiness and Professfons Cocl��7he Con!roc-
inr's llcense Law docs noi cpply to an ox�ner o1 prop�rfy
__ ____ wno bui(ds a:im'sraveh�h�rraw,aad m-ho mntroBs�or
sucb proje:fs wifh a conircdor!sJ limnscd pursuonf to
� ihe Centradar's license Lav,).
1 om exempt�nde�Sec. .
B&F.C.for th�s reoson
Date
. .. . � � Owner_ —
iNSPECTOR'S NpTES .