HomeMy WebLinkAbout1006A �4'OILKGI25'CU\1PICNSATIO\D1:CLARATIOti � 7GA364C ��PLICATIOf�! FOR� PERF�+iIT
1 hereby afCirm [hat [ havc a'cerlificate of conscn[ [o sel( CE-816(2�8D) �
ins�re.oracertific�tent�5'orFers'Compcnsatiunlnsurance.o� HCqTING-VENTILl+TING•AIR CONDITIONING
❑certified copY thereot(Sec.3800,Lab.C.) .
Policy No. Company,
I ❑ Crrtitird cnpy is hrrrbs'rurn�s�ird, COUNTY OF LOS ANGELES BUILDING AND SAFETY
� C'.cr�ified c�P>'�+filed�vith ihe coun[}�6u�(SinF�n.{�ection EUILDINC
d art er,t. � FOR APPLICANTTO FILL IN nooFless I�� �'L�('U/'--���.
I)�te��Applic�nt� (PRINT OR TYP[ONLY1 —
� LOCALITV �� L�j y T�
CI�;RT117CATf'.OF LXL?1NTION I'ROS7 R'ORl:F.KS' NO. TYPE OF ACPLIANCE OR EQUICh1ENT FEE
C011F'ENSATION ItiSURANCE I CROSS ST. �,./ /-t/f � Cr-
(Tllis S�ction neCd nUt bC Cortfpleted 1(the ��Ork involveS �AQSORPTION UNIT,6TU _ 0
by tlie permit is far one Lundmd dollars (5100) or Icss.) oisrr+irrrvo. rnocesseoav U
AIR HANDLING UNIT,CFM ///���
1 certi`y tha[in the prrformance nf the�vork for wLich this � a
permil is issued.1 shall no[cmplop y person in any manner I � . O
so us to becume subjett ta the�Co�ers'Compen itinn La���s. BOILER,�TU
� p FlPPROVl�LS DATE I >vEC1on'SSiGvnTURE �U
n�tc.�+,��=.F.1��pD�������� � COM17PRESSOR,BTU- ROUGH �1_ _�-1-C N
%
N07�fCF.7�0 ANPLIC:\tiT:If,atler m�king Ihis Certific�te of VENTtLATION S�STEM FINAL ����� ?
F;xernption, you shauld M1ecome suhject to Ihe lYorkers'
Compensation prnvisions nf[he Labor Code,you must forih- EVAPORATIVE COOLEF VALIDATION
with comply with such provi;ions or this P�tmit sh�ll bc
deemed re��aked. FURNACE: FAU�_G(lAVi7Y-
WCF:M1SI;DCO:`fTkACTORSDF.CLARATfO\ FLOOR: oTU
I hertfiy affirm Ih:it I am licenscd under�r��vi:ions nf Charter HEATER: SUSPENDED UNIT
9 (rommcncing with Srctinn 7000)of Division 7 of the Busi� WALL
ness and Prn{essions Cude.9nd my license is in full force and y �
- eRect. p� � �D'I �
License Num6er l.ic.Class .
Cnntractor Datc
� 1 am exempt from the licensing requirements as l um a
rccnsed architect or a rc�t cered Frorrszt�n�i �ng���t�•r p�an check fee 25°�of above.
acting in my professional capacity (Section 705I, Clus-
iness and Professions cude). PERMIT 1SSl11NG FEE S � �D
tic.ur ieeF.N<,. oa�c TOTAL FEE �,1� ,y� �1 G G.6 A
110\fEO��'NG(LBUfI,UCR DI'CLAKAT[OV p�qN CHECK APFLICANT �� ��� � �8
I herebp affirm that I am esempt from�the Contrac�or's NAME
l.icense La.v for ihe follox�inK reason (Section 703L5, Ilus�- I•• •2 2.��
flC5saf1�I'foCl'�Sions C�ode): ADORE$S � •t
� I, us oa�ner of tLe properq�.�eiil do the H'orA anA the. � • �2�'`J�"
s[ructu�e is not intended or uffered for sal.: (5�•cti�n ��TV TEL.NO.
. 7044,Businrss and Prn(essions Codt). //��
� OWNER^-7�'��_�•l / '.t���/i-r�
[,as owner of thr property.am exciusively coninctin3 •� 1_�f'J�J L
•ith lictnsed contractars tn construct thc projrct MAIL � A � 0 8 1 2-8 3
(s��c�o�7043,pusini•tisane!v�oee,s��rt�Code). AO�RESS ��___C�-L��<<�%��'
CITV _� TEL.N j�
CO^1S7ILUCTION Ll:NUINC;A[;I:NCY .J_f � �J��
^reAy u((irm [h�t there i.a u � nstruction iending nFrncy CONTRACTOR / /�� ' �
ihe performunce of tha work for which this permit is G�J �
•:d(Sec.3097.Civ.C.).
der's M1ame ADORESS j j` � /`„ f. Li�q
l�! !G=l=.J'
:�der's Address CI7V TEI.NO.U�^J �Cy` .
�vr[if��thst I ha��c re�d this nC�lic�ti�n and sfafe tli�t thr 5T���7 � LIC. r `/'
LrC Infafm�tlon i5 ct�rrect.I a�.ree�o com��ly��'ifli all CuUnty LICFNSE NO. �/ C�A-`'`` (r���„{ -
iinances snd Statr Ia�rs rugulatinF�����ing.VtntiW[ing und
�Cond' oning.and hrreb5'authori<c«•prescnt�tivrs of this Stil:R]>�'IiR54;FOK FXNLANATOIiy LANGUAGI;
.uuntY' lo enle upe�r the a � r-mrntioned prupenl' tor
iusptc nn purp� es. � �C�
��i ._ ,�1'rrmit re Uate . . . . . . . .
. IPJSPECTOR'S NOTES
� � � � � ON'NRR-[zUILDLR DLCLN:ATIO\
� � 1 hcrcUy affirm tliat I am c�empt Gom tllr Contnc[ur's
Licensc I.��c fm tLc follo�cing t.asnn(Scrlinn 7031.5,
� Uusirress and �rofeseiorcc Code): Ar;r clt}� or cauit}� ,
_ . w�lrirl� mcir;'rrs n p:•nnir fo cor.crnrct.�e7ae�, rm��rore,'�: -
. � ' � � � - �. -• �� . . demnlisir,or hpair ariv SfRIClI1�C.(�rior to its-�icsrinr.ce,
. a1.ro requirec'die cpplrcanr j�r suel� perinir.�te Jil; a
. . . ' . - signed tta[<�rnerrl fhr.t !�e ic lirciued purs�m¢t fo the �
. Prorrcinris of ri�e Cortrra�rnr's� I,irensc Lax� (Cha,nter 9
� � . . � � � . (coinr.�eirri�t; �ritH Sc,rr^n 700C! n_(Dirirro❑ 3 nf tF_e
� Pitsiness mut !'�njessioirs ('o;teJ w tl�a! he is cxenrpr
� . tho�efrorn and!he Gasis Jor JAc al(eqcf e_cernption.Any.
� ... .. - . vinlction of See7iwr i031.5 Gt�c!:ti�cPPlicc^t foraPenni7
subjec�s�l.e applicmrr m a cirii pcnal{t�nJrrot morc 7h.mr
� five hru:rhed dnlle•s($cp0/.:
. ' . [_} 1.a.ou'ncr nf thc properq't��ill Ac��the t�url„and
thc situctc[c is not�intrn�lcd irt o(f¢rcd for s�l:.
- � . . - , ' � /Sec. 7DJJ, A�csin�ss und frnjcstsiwis Cndc: Tfre Co++-
- � trarlor's Lrrense Lcw docs rior cpPl�� 7o arr ox���c.�of
� prvperry�ol�u h+:ild.c or irr:prores rl:erea�,anA xRo does
suCh �cork himse(f proriJcd (hat sttrh iir�p�uremerus
arc no! Irt:end.�d nr pff��red for sale. If. hm,creq thc
bui!di�t4 ar 1/IItYOPC/!!MI( rr sofd Kdtliin anr }•ear of
complclion. �ke mcnervbuilder �vifl l�m�e dre burdei:
of lvorirtg rkai he did not b:lild or imniure Jor the
— � � , . � . ,. , prvpoac otscfc./ .
� I, as owne:u(thc properq�,am cadusivcly con-
Iractinq�ricii li:rnscd contractoa tn cons[ruct tLc projcct
� (Scrlioir 70�1.1. 6:esi�re.cs cad R�oJessiorrs Code:7h��Co�:.
trac�or's f.icrns� Lax docs not appl�• ro arr oxmcr af
propertp v:ho builds or improres �H:rcar, artd rcGo
, contracts fnr st�cG projects�citlt c em+nncfur(sJ li��r��sed
� � �. p�ersum+7 to the Cnrnrn�rur's Lirensc La�vl•
1:im esempt m:der Scc.
� E3 C f'�.for this rc�>on
� Dat e
. Owncr -
.. `�"
'\ -
INS?ECTOfl'S NOTES '. � � - � . ,
i . .
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