HomeMy WebLinkAbout0970A (5) �'`°�'°S""°"°E"AR°'T'°" APPUCATION FOR PERMIT �
�I he�ioy afPirm thef I have a cer�iiimte of consenf fo self
' sure,or o certifimte of Workers'Compensation Insmance, �6A364C HEATING - VENTILATING - AIR CONDITIONING
�or a certified copy th�eyrleof(Sec.360D,Lob.C.j g� CE-eIB(REV.ID,'el�
�tyNo,�t�.�"7Tl Compony ��L�c/�
Certifled capy is hera6y f�rnished. COUNTY OF LOS ANGELES BUfLDING AND SAfETY
Cenified copy is filed wi�h�he counry building insper POR APPLICANT TO PILL IN auaow�
tionde�i/,1,�.� ADDRE55 ��� Z �-�
'�. � (FRINT OR TYPE ONLY)
Dnte Applicam ����TY ' _ � .
NO. TVPE OF APPIIANCE OR EqUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORK 5' NEAREST
COMPENSA710N INSURANCE CR0.55 S7.
(Tfiis socYion nwd not hr<ompiN�d ii ih�work Involwd by ABSORPTION UNIT,HTU DiSiRICt NO. PROCE55ED BY
fho permif Is ier ona hundrod dollars(5100)or less.) f� �_
I certify fhot in�he performan<e of ihe work for which�his AiR HAND(ING UNIT,CFM 'V •—y)
permil is issued,I shall no�employ any person in ony manner BOILER,9iU l
so os to become subjec�to�he Workers'Compensa�ion Lows. ( }� avvaovn�s onte iNsve[roa�s s��cNntuRe
Date Applicpnt COMPRESSOR,BiU �n L/��ij eJ-O �v ROUGH '
NOiICE TO APPLICAN7: If, ofter making �his Certifica�e of VENiiwnON Sv57EM FI�Na� _ L
Exemption, yau should become s�bjed to the Workers'
Compensalion provislons of the tabor Cade,you must for7h- EVnaORA7ivE COOLER vauvArioN
with comply wilh such provisions or this permit sholl be
deemed revoked. ^� fURNACE�. FAU,_GRAVITY
IICENSED CONTRACTORS DECLARATION J FLOOR BiU ��OD
1 hereby affirm that I om li<ensed vnder provisians of Ghapter 9 HEATER SUSPENO[� UNI7� �
'(commencing wRb Seciion 7pOp)of Division 3 of the Business � "�'A��
� and Profassions Code,and my license is in full force ond effecl. ` J� y Q ,�.d 1 ,v �
s ��ZQ M.,.C.tiCo 1n�tiC,t�o ��9��)F, V
License Numb Lic Clos ►
�!s e c a m� 0c
Coniroclor � Date�^� p
❑ I nm exempf un r ec. ��'o"'+��9d � �� C�.C�r W
Plan check fee + • 1 �:;G Q�: �
B.&P.C.fo��his reason PERMIT ISSUING FEE s �� .h�
Daie: U�� ��C:�
Signature TOTAL FEE � (s �
OWNER-BUILDER DECLARATION P�AN CHECK APcIiCnM
I hereby affirm tha�I am exempt from�he Controctor's License �
Law for fhe fallowing reason($e<tion 703L5,Businexs and NAME
Professions Code):
❑ I, os owner of fhe praperty, o my employees wifh A�DRESS �
wages as their sole compensolion,will do�he work ond CITY TEL NO.
the structure is not infended or offered for sale(Se<tion
7044,Business ond Professions Code). • �
pWNER �
' ❑ I,as owner of the property,am exdusively comracfing
with licensed wntmciors�o mnsfrucf fhe project(Sec- '�'a��
tion 7044,Business and Professions Code). ADDReSS
CONSTRUCTION LENDING AGENCY CiTY iE�.NO.
I hereby atfirm Ihaf fhere is a construciion lending ogenry fo� ' /
1he pe�formance of the work for which this permlt is issued CONTRACTOR {��y � � �, ,
.(Sec.3097,Civ.C.).
AD�RESS �� ��/
Lender's Name �/
—rv
��TY u,�,�y TEl.NO(� 0��3
Lender's Address ��
STATE llC.
I cenify Ihot i have read fhis applimtion and sfo�e rhot rhe uCENSE NO. CLASS �—Z(�
o6ove information is conect I agree ro comply wifh all County
ordinances and Store laws reloting to 6uilding construction,
an hereby aulhorize rep.esentalives of ihis County to enrer
u 1the o e-me noned property for inspection purposes. SEE REVERSE POR EXPtANATORY IANGUAGE
�'s J i�—��
SignaNre of plicant o.Ageni Da+e -
I bk'3 t@b d'1�-�!Jl6�@�1.4i11471�d
I hcreby at£;,m�hat I a eae�mnt frorr,iho Controc�cr's
Llcensc Law far t{ie 4olriowinp r . n�(S�•ction 7031,5,
6usiness ond Frofcssions Code)�nny�ity or caonry which
^--�-----�— rFquires o pFxmit to ronstruc�,cf�or,imc.ove,demol�sb,
. w rcqsa'rr ony sirucfuro.prier tc rts is•,uancc, olso r
� GYJfCF f�:1 O�1lG:1�fK SUE�1�"Mlf IL�1{I�G?.�OB S�CfC-
m�ni fhc!he Is ficercd pursuaN to 1ha p;ovi,ions of the
Conirocior's Liccnso io��(Chaptcr S(co� encinn wifh
Section 7000)ot Divisicn 3 el thc C��siness and Profes�
— sions fock)or thw he is ex�>roRr tncrelrom and ihe basis
�or 7he afle�cd e m��ion. Any violenon o( SecNon
� — 7037.5 by or,y ap�tflco.�f/or a prrmir subjccfs tf;o appli-
. canl lo a civil penaley o�not mo.e i}:an Irve hun�rcd
. � '-'- dollars(5500).:
� C�I,as ow�ne�oi ihe propeny will da the work,ond
— �h�strocture is not inr�nded or oi�ered for snle_
� (Sec.7044,Gusine,aondProfessior,sCode� FheControc-
, - tor'a Licrnsa Lovr�e�not cEys!y�o an awnar of prnperty
� who 6uilcis o impreves �heraun, aad whe dows sudi
" work hrmself provid:d 7hr.t socfi im�ovamur�3s we no+
� intcnded or olfored for sale!f,hcw�r,�er.fhe bui!din2 0�
- � imprmvarrwnr is ssld wtihin er+a year of complatls.v,�rhe
owncr-botlder w'rll hcre thc burden of Froving t#�at he d�d
� �O/�pUI�L�Of ll��F'..'6V6{Lf}}2 Rllf�>-'+5?Gd'f.lE�.�
� � � ❑i,as ovmer ot the prc�+Frty,am exd�usively con-
acY�ng w�dh lic�sec co�as+ar=_to mn�*run the nro'iec�
_ __ f,5ec 7041)Husincss and Profc�sior;Cc+F.��:7he Confroc-
ror's Licanse Lc+v dces nef npp�y fa cn o ncr af property
_ _ who 6uii:s or Improvrs tl�cvaen,end v�d:o con�recis!ar
such projxh wit'�c eontrccfar(s)lice,^scd purs�en+tn
thc Controdor's Llccn�;e La�NJ.
I om exempl under Sec.
B 8 P.C.for this reason—._—.—__.____.�__
Date
Qwner
INSPELTOR'S NQTES