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HomeMy WebLinkAbout1578A WORKP.RS'COMFLNSATION�ECLARA7lON 76A364C �j 1 hereby aTfirm t}iat I I�nve a'certiticaie of consent tn setf CE-S18(2�@fl) ��f'�P'[�PC Al"1 f��F FQ R P�F?M IT � inL�fe,or a cert�ef��te otw�rkers'copapet�e�ox[ns�r:inee,or NE'<,71f°dG-YEM1dTi'ILF�TIh+G-f�IF'. COPvDITIOP�IPut=' a� tified cnpy thzreof(Sec.3800, �6. , �� Nolicy No. Company I ❑ cercifica cony i,nareny tu�ni,nra. COiJRlTY D'F LO�AhG�LES &Ui LD{f�G 14NL1 SAFETY � Certifietl copy is eled wifh Yhe ca �b ildin�inspeetiun �' �' d ar men�t. �," /' FQR APPLICANT TO FILL fl�l QJILDING ^'� }� �1 llatz��1_��'�-ApPlican[.�__<6;Z��C_..�..��_ IpRINT OR TYPE ONLY) A DftCSS, � pc��./ ._ __ iI i LOCALITY CERTIkICATE OP EXFNPTION FROM11 W'OttKElLS' NO. TYPE OF APPLIANCE OR EQUIaR1FNT FCF __ _ __._ __ _, ,._ _ �..'_�_.___�.�._-- CO�iPL'N$ATIDN[NSURAtiCl: �� tVEAREST �7�.�, }���w� (This section need not be completed if tl�e woxk mvolved �neSoaP7iorv uNir,e7u , cr�o��S s'r. ��L�'[.C.�/�w g by thc permit is for one lmndred dollars (5760) or le:,s.) -- ' — --����� I- � -"'""'�` : o�r �T��, PHo�Es�E f�� i $ T ei�ctify th�t in tlle pecforman�e ��f the tc for wh�ut�ihls AIR HAND�ING UNIT,CFVi— -"__--_-__—_ �-____ _,. �....'�. S permit�s issued,I shsll nnt emplo} any prrson m an}manner .i �d �,�,etf so ar t<�hecome suh�i•et to the Norkers'C.orap�nsat�an La.�s BOILER,BTU � Q . . ._._.__. .,__`� � APPROVALS DATE i in;PrCrLn'SSicrvqrur+=_ W Date Applicant �-- — —-� a - -- CORWR&SSDR 6TU ___ ____ �rjUC3H y _'._ �.. _ ... NOTICh.TO AVPLICA[+T: [f,after making this Certificste of - --- --�� '� , Z k:xempt�on, you should be,ome VENTtLATIONSYSTEM - suhject to the 14'orkers' I fINAL � �� �� � C[�i31 Pfi43t10� _ --.....—'—_`—"...�___._____ .`."_._ P provisionc of the Lubor Code,you must fo�th- �, witfi cornply with suc1: provisiona or [his permii sha8 bc EVAFORA7IVE COOLER . VALI�ATION deemed re�oked. � -- --�--- FURNACE FAU,cOD,F+::1.�/_i � LICF.rSt;nCD�l'RACTORSDl[CI.:�RAT[ON FLODH'_._.__BTU__(]V�^^' . I� {�{t (� c., � I hereby affirm tlm4 I am licensed undet prnvisions of Chapter HEATER: SUSPENDED UNIT � iy��� Z'�-!�O�"� 9 (c�mmencinK w'ith Sectiun 7000}uf Division 3 of[he Busi- VdAIL ness and Yro4essinns CoAc,and my lieense is full f ce t�r�d � � in effect f L�cense Numb� a"I��� Lic.Class � _ � - / �` I -7 T —. —__-_. ___._._ .___._ ._'_�'_'_ Contrac[or___=_,� Dntc�i.���_/�,Z � � [ara eserHp from ttFe liceesinp�require�n�nts as 1 asn a _,., __.__ licrnse�3 amhitect ar a stareA � �e�+ �ore«siexai �r,Er Pian cheek fae:?3Y of above. actine in my profession�l eapeaity (Section 7051, �us�� -� iness and Prof,.ions Code). _` _PERMfT fSSUIP�lG FEE S", ��! ��5 7.8 A L���.�r xrg va. �a�e — - _ —�TOTAL PEE ._�� #�. •.�. .8 I[O'.l7F:OW'NLR-BlIiLDFR DF.CI,ARATION PLAN CHECK APPLICAN7 ___ `_� k•�����Q I hereliy afCirm that 1 arn�eze�ppc fro��the Contractnrs roqry�E License Lan�for the foltowing reacun (Seetion 7031.5, Suv- ----------------- �.��'L>�F�I�� no�s and Pmfessiorts('odo): ADDRESS ' ' - � I, ac owner pf the proF�ertY��+�I�I cko t�ze work and Che -� ----^—�-- ����'�'��^G structuro i� nnT intendedt o:smffeze usiv�lv con�r��t1Un CtTV TE4.NO. a saie (Szct 7044.Rusiness nnd Frofessians(7ode), �----- - ----- -- j � [,as o�a�ner of the OlNNEF `��, s. ( -i � p��P y, . , ;ng —`._.__ .rS1���.wlJ ith licensed cnnhaetor,s to construct the project MAII. /y /� (SecNun 70�R4,Dusina�ss and NroFessions Code). AL70R6S8 � �/�/� 11• � CO�STkIJCTIpT:N LENDI:VG AC;F_.NC'Y CI7Y —� „_ „/ 7"E .NO.��� I hare6y affirm thai there ia a c ;trueiion IendinK agencl' �Lv,L -_ � un for tlie performance oi' [he work for which this pennit is CONTRACTOR � � . issuzd(Sec.3097.Civ.(;.). - - .---.._.-_'.'. k L - A�ORESS ' � Lznder's Name �f^ --` - -��, LJ Len�er'sAddrnss ---_- CITV TEL NO ��a2p7� 1 enct�fy that I ha�e read th s appl��ution and state thal Yf�e - ��-- - - � abuve rc�mation�s conect.I�gree te�com�ily with alt County STC�eNSE NO�� ��,�yCLAs Mo ��,� . urdlnan � erid Stntr laws renul�4ne Hca7ing.Ventila[ing and ' �� � ��� �"" 9ir Conditinning,and hereby uuthorir,e representatives of this S1iE'Iik:b'F,RSE i'OR�:XYLANATOIiY LAK(;UAGh' County [o entec upnv the �bovc-mentioned pr<�Pz�7y fnr uisp �-pur�o x ,. o� �.��.2. _ Signntur F'ermCttee Date � � Ifit3PECT0t�'S M1aTES �.. � � � ,:i:-��U:�G;'�i":.�rCS.:.:=�',i{Q"� � .�� _ - 1 1�::r�4.1�aftir:��,i�.ct i n-,�i czcc;,;(:�.�,u tl�.��Cun¢2.�c;or's -- . — i.icens.• f_::r t'_�, ;:-. j.,�'h:°�Str.r,xca����.n l(r.�trnn %G91..F, P...siree r a.�:l I'ri e ��. � Cr .�_J; A:�o ri!V or car�nty . . ._ r,Fair7! r�,.,�:7r.�c n pr;���er to co�r:r.��s. r7;rr. irrtprcre. � � d'r.�:ol5 r-r<;=r. r;sn.r�u� � ,r:�<r;lo irs rn'�ua:cc. � . ' — nlso rq�ri.�e; r1,� cr�,:ri::n�r jnr sir_..`, ,>r.,-niJ [o f,ic a .. . ' - sig•,��d vctern�n: tL�af 7ic- i� lice��;<�t' pio.eu�^tt ia t�;e � — - y�rorisim:,: e;: tl�c Cnrtt;a^tor's Licensr Lcw (Ci:aPtrr 4 � � -' � - � �tonneicrreiq;- x•;:k SFc�ion 70C'�,l �,f Divi.ra: 3 of tlrc � ---- fii�sni^s, rz�rd i5�njrsciu::.� C'or,!•! m tlra� {ze is exeur;�f rizrra�rc,!:r.r.,d rhe fi:�s�r j�„�dre c'f.r'ea!e:ceu„ztinn.Any � . vr,�ln!!nn oj 5rr7'�m 7l731.5 1;�n�tr r��rp7;rut,p f.^rc p'=�vait a�b�.uti Il�a,�_•,'.r�rat�t�a=-: (�r.ait,��r�f i,'r.r��reth^,: — � fi,r franihrd dol;,��-s i3:OJ1-� . . . ❑ L a,a��.rr.c-Arf thc pro .rt? �ciLl d=�tlre�;urk,and _ � fl!o skrn�li�.-�_i>nu�ie�c�uPcd nr nfi�s��,!(ur szlc. . (Suc P - B.;:u.�t c ' f; sior�t C<.�-:': 7Ar Ccn- _ unrtor's Lirerrrr L^r.�d�i_, �,o! c -v fo r.rs o�arser nf prapr�iy� �r(ru hri?J�:n.i;n;.ro��e�;/�.�n �.uu�l w/m dars � � c:rdr �. :. !�i»:rcli prot�i�",•d rlrsr s.�rl; i.�:prorrnienl; . .. � .. . ar,� r, _ ut rr'rd .r ofJ,�rul�cr.v...�. 7� 1 m�c,.er. tfr.- � � ' b�lddiw� r,r imrrure�*iriar ii i��fd�c.�iffein nr�. �ria�� uf . cortthfe:i��n. tke ux�r,er-!ri-itd�r xv(j h.,.c 7"ve $urd=r� of�^-ovitr;; 71ta: !tr n'."t,' i!ct Pui'd u: ir,�n�q;�e for Yhe purpnsr of s.rlr:.j � , t] l. a€mtiner of ihe proccm,,n:n vxcfustvc]y con- lcictcv,�vitl�L+eee.r?enn.rr,l����;to c-rnstn!ct[lie pru,jeei /Secriovr 70'1, 73hsi:�s�r ru+-J urrrf.rslnin�(Lrr;,.:Tb.�Co°r- trnrlor's Lrc���:;c Lc�v dor� �zot pf%Plr..., .r� o�vncv ef p�<>p.rty �+�F;o 6in�;?r or i:r:i�rnres v/Ic�c<YN. c�nd x�r:o _ cwvv,�f�:e�`iir�..tc;; J:�i�jrrts i��i!f.ocmurrcl��r/sl ]icerrrcd � _.��: �:�. ;� �� p:tr...:^�-:ri!!u th:Co�':r�::;;ar5l.irans-:-lcv.•J. . . s . � . , - ____ �FP;➢e3'e[n�i V.t�t.l:�.n':C.�_�.___._.. � . � � ._ r�".T,.t..�l)'t�l�.;_�+r1C:-_."—...u_�_..��,.. 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