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1245A
— ,.-�-------.,� WORKERS'COMPENSATION DECIARATION /�� �^��+ � 1 hereby aSfkm that I hove a�e��,���a�a of�o�,e�,,o=a�t APPLICATION FOR PERMI7_ - insure,or a certificate of Workers'Compensarion Insuronce, �aA3aaC HEAIING - VENTILATING - AIR�CONDITL�NING or a[erfified,copy thereof(Sec.3800 a .) CE•BIe(REV.IOiB1) � P❑olity No ��Company � _ . . `�`�^ .•-..,.� :' Cerrifed copy iz hereby fumished. COUNTY OF LOS ANGELES BUILDING ANO SAFETY �CerNfled copy is filed wi� ha cou`ty building��sPeo- - FOR APPLICANT TO FILL IN suiwiNc hon depar7menL (PRINT OR TYPE ONLY� ADDRESS � Dale � i N Yi( LOCAIi � NO. TYPE OF APPIIANCE OR EOUIPMEN7 FEE CERTIFICATE OF EX P FROM WORKERS' NEAREST COMPEN TI INSURANCE CROSS 5 (This s�c�ion n��d not b�completad I(1ha work involved by ABSORPTION UNIT,BTU DISTRICT NO. PROCESSEO BY th�perm8 Is for ons hundrad dollarf(SI00�or less.) q�R HANDLING UNIT,CfM `L � I cerrify tho�in the performonce of the work for which this , permit is issued,I shall nat employ any person i�any manner so as to become subject�o tha Workers'Compensotian lows. BOILER,BTU hPpROVALS DATE INSPECTOR'S SIGNATURE Dafe opplicanf COMPRESSOR,BTU ROUGH / — � � NOTICE TO APPL�CANT: If, afler making this'Certificata of / VENTRAiION SYSTEM b � FINAI ���,f j j'� Exemption, you should 6ecome subject to rha Workeri Compensotion provisions of the La6or Code,yo�must farth• EVAPORATIVE COOLER VALIDATION with comply with such provisions or ihis permif sholl be � deemed revoked. . ' Fl1RNACE: FAU_GRAVITY tICENSED CONTRACTORS DECLARATION . FLOOR BTu 1 hereby affirm fhat I am licensed under provisions of Chapter 9 HEA?ER: SUSPENDED UNIi_ - '(commencing wiih Section 7000)of Division 3 of ihe Business V�'Au � ond Profess�ons Code,ond my license is in fuil forcne and eifecL . +�O � a License N m6e���ODr tit.Closs v �Q /� � V iYt'✓�t�-p �=� � Co c r afe � � � 0 F exempt under Sec. w Plan check fee y 8.8P.C.for this reoson' PERMIT ISSUING fEE; �� 2 G.b A ? Da�e: 5gnature TOTAL FEE '�• • • • •8 OWNER-BUILDER DECLARATION PLAN CHECK APPliG4NT � I • •J�+O O I hereby affirm thot I am exempt from�he Contmctor's License � Low for�he following reoson(Section 7031.5,Business ond rva./�nE • • �3�G 0� Professions Coda): � ❑ I, as owner o!the property, or my employees wlth AD�RE55 I Q� .rJ—H fI � ages as Iheir sole compensalion,will do the work ond � the srructure�s not intended or offered for sale(Seaion ��TY � Tei.NO: 7044,Business and Professions Code). OWNER ❑ I,as owner of tha propeny,am exclusively controcting MAi� wilh lirensed coMmcrors to canstroU the project(Ser qD�RE55 � � lion 7044,Business and Professions Code). � , , CONSTRUCTION LENDING AGENCY CITY . � TEt.NO. I hereby offirm that there is o mnstruction lending agency for � , the performance of Ihe work far which�his permii is issued COt�TRnC70R � � e �(f� �i � (Sec.3097,Civ.C.). � - . � � ADDRE55 ,¢ ��.��� � - .. . . . . _ Lendei s Name � Lender's Address � CiTY _ �QW�� TEL.NO. 6�� (� . _ SiATE �7/O��J UC. I certify t r I have read this applica�ion and slaro�hat tho IICENSE NO. � CLASS C' L� . . ... . . abova i ormation is correct.1 agree to comply wiih all County ordin ces and State laws relating�o building conslruction, , ereby au orize representa�ives of this County to enfer � � . �on iho obo �sioned p�dperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �Jl�i'�tc�� Siqnat�re o(A lic ni r Agent Da�e � , � � - . .. . _ . . . .. . . ._ .. . .. .._ � 5310N 5.801�3d5N1 � J3UM0 . �- � -- ' - . . . . al�a . . . ... _._ . . . . , , .. , uosoa�siy��o}'J'd'8 9 : . , � . -� .- . . •�as�apun�dwaxa wo� . . , , . , � .�(.ko7 asua�i�s�07�o�luo�ay� - � - --. . . . . , . � . o��uonvnd pasua�i��(s)lo��o��uo�c y��.n sj�aJo�d yons - . � � � � �� �� � � � � " �o�spw{uo�oym puo'uoa�oyi s3no�dwr�o'sp�Inq oym �- . _._ . .._. . . . � . _ .. � .(l�ado�d�o�au.Ho ua o�A�ddo�ou saop m��osua»7 s�o� � � � � . .�oi��uo�vyi:apo)suoizsa�o�d puo ssau�snB(CVOL'�aS) - ; - � - - � - � - palo�d oy�pnqsuo�o�s�ot�onum pasua�i�y�im 6uipo�i _ i -ua�R�anisnpxa wo'A��ado�d eyt)o�aumo so"��" ` . . . ..�_ . _ \_' .__ . t.� ,.-���_�;":1.4.... - (�o�os�o wsod�nd ey��of ano�dwi�o p��nq�ou� - ��_'_ �• " , P!P�47oy�bu�no�d�ouap�nqoy�enoylfp�n�ap�lnq-�sumo. - ��- - '- - - . ... . . . . . - . ayt ruopa�diuo��/o�oF.f ouo ury�im p�os s�luewano�dwi � � � � � - �- ' �o 6u�p��nq ey�vanamoy•���o�os�o�po�a��o�o papua�ui . - -�� - - - � - �- �OO�ID S�OOWdAOIdWI y�ns��y�pap�no�d��esw�y��o,v, -� - � y�ns-saop oym puo •uoa�ay� sano�dw��o sppnq oym . -" � " �-- �- � - � � � -. .Q�ado�d�o�aumo uo o�,(�ddo�ou saop nno7 asuav7 s�o�� � '� � � � _ ,� � .� •�o��uojoyi �opo�suorssa�o�dpuossauisng'yqOC'�a5) � - ' � - -� � - �- , . �', _ . '_ .. . _ __.._ . .._ . _a�cs�o}paio�}o'�o papuaiu�'�ou s�oinpn��s oy� � � � �v��. � � � puo'�io�,ayl oP IU�n Auado�d ayl;o mumo m'I❑ '. . . . - . -.. . . -_. . -. _ . .. � ' �'�OOSS)s�o��op . _ _._ __. '.._ ._. . ... . _._ . . . ' palpuny ortr�uoyl o�ow lou�o.f��ouod j�n�n o oa�luw �� . � . . . - - ..- -- - . . . . � . . � �. . . . .. _...r_____.__.__._._ _ _ y�ddo oy�s�oofqns�iw�ad o�o�ium��ddo Scuo�cq 5'l60L - � � uop�ag �o uoii4�oin .(ut+...uo��dwa:a paBa��o ey�_Jo� � . . . ... -. . . . -� . s�soq ey�puo wo��a�ey��dwozo sr a,y�oyy�o(opo�suors � - � � - � -sa�o�d puo ssaursnp oy�)o E uo�sl^IO!°�OOOC uoqoag . . _ . . . -- . . '��. _.-. I � � . yi�m fiupuowwo�)6'�a�doy�)MO�osuoo��s�opo��uo) � . � � - � `�1:'• `;�,`. `�l� '_ ey�yo suo�sino�d ayi ai 7uons�ndpasuan��s�oy�cy��uaw � , . , , � � •� -o�ois pou6�s o�ofr�o���w�ad y�ns�o�{uo�qddo oy�so�/nb� . " � , t F 1�.. 't 'i^•. ' �_ j,'.� -oi os�o �anuonss� sq o��o��d�o�npn��s 6uo.+�cda��o . . ` - � � � , 'ys��owap�eno�dwi•�a��o'��n»suw o�llw�od n se�tnba� .. . , . . ���- Y�.:�\;, , �`�.� ���q r .. . 4�14^^R�uno��o6�p6uy:(opo�suoisfa�oidpuo�ssaulsng� `_"..._ . . ..-_' .�_.. �.. : �..�.... __ .__... ._.... ._�... . ._. . . . .. .. .._._._._�_ � . . � 'S'(£OL uo��pas) uosoai�6wmo��o} ayy �o} mo� osua��� s,�oPonuo�oy�ww��dwoxa wo�!oy!w��y�o.(qa�ay � . . . . .. , . . . � . _ . .. ' ...-, 'NbI1b21�f1J30 2i3411f19-?13NM0 . S3lOtd S.L01�3dSN1 � . � ;t - . , . ` �,.. ., �--�^` , "----=-_ "_'�__�