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- - i , , � WORKERS'CORtYENSATION DECLAAATtON - ?6A364C � � . � ' . 3 hereby affirm.that�I have a certificate of consent to s��f �- ��-818�2-ea, -:�A P P L 1C A�T t O N FO R��P E R M IT - : n ce:t3fied capy thcreot(Scc.3�0�,La6PC.} HEATING-VENTILATING�AIR C0IVDITIONING , � msure,or a certificate ot iVorkers'Com ensation Insuxance,or ' , i , . , . . . . . ., ,.. . .�.__ ;... , . , . 9 � � YolicY Na. CompanY ..` . . ...� . . , . �� ❑ Certified copy is hare6y fumished. COUNTY 4F L03 ANGELES BUI LDING AND SAFETY � , � D- Certifietl copy u filed with tfie countq 6uilding inspection� _ � . department. FQR APPUCANT TO FILL IN aboREss C1��fi.t� �l/� � Oate_ Applican[ - IPRINT.�Ofl 7YPE ONLY) ��, � -NO. TYAE OF APPLIANCE OR EQUIPMEN7� . . . .. � �FEE � IOCALI7Y �.�..�' � . �. .9. ... �'CE.RTIFICATE OF EXEh1PTION FROM�WORK£RS' � 1 ' � � � �� COMPENSATION 1N3URANCE �� ' �`'�� �. -� b�j - � -. M NEAREST � ,� � �; }- � ` (This section�need not�be completrd if the wo�k�invotved 'ABSOFPTI rv�U�v iT;s7u l �� Q. caOSs s7:� ��`� � �� '.`8 � ; 3 ' by'the peimit is for one hundied��dollars ($100)�ox IessJ '�� � . , � � oisrwicTNa � vaoce eo i � �� I I certify that in the perFormance of[he-work-fot whiCh this � �AIR HANOL WG UNIT,CFM - � �� . � . � a , � permit is issued,I�shali noi employ any person In an5'mannec"�' - . . -.� - _ � � �. �� -.� � ` � ,.3 � ��� so as to�become Subject to the W.rkees'Com " sation aws.�.� 86fLER 8YU - �� �� APPflOVAL$. OATfi . �NSP�CTORS 61GNATVRE � � Dete - � Applicant�� �� COMPRESSOR,BTV y. i .. ;. , -� ftOUGH� � � � : y .. �.NOTICE TO APPLICAN :Ef after makin is :r ,ica e of � ,�VENT14ATf�N Sti5TEh9 � �� FINAL � �.�� Exempt�on, yod-should ccome subjec ro t e Workers' � -Compensation provisions of the La6orCode,yqu musf-forth- . -.`�, EVAPOFiATiVE 404LER� -���� � �� � � � � � ��with comply With Such provision5 or This�yermit st�all 6e � � � � � '�/A�..��/�7��N � � ! deemed�evaked. � - �- � � � � ' � FURNRCE:��-FAU�..��GRAVITX_.._� � �. - � . � � � � � ? �� � LICENSED CflNTRACTORS DECLAR ATICJN - � � F1�00R: � �-BTU - . . � � � � � I hereby-affirm that I am licensed under provisions of Chapter � ...HEATER:....SUSPENDEp �.UNI�T � � � � � ' . � � . 4�(commencing with Section�7040)of piv;sion 3�oF the Busi- � � . �WALL �,. � � � � . � - � � � ness and Professiona Code,-and my license is in'Su1P torce��and . � . , � � - � - � � �� � � Bre��t. ��1 2 9,7 A 4 License Number �� �.,_._,� �_, Lic.Class � � • . . �, . � . i , �, , :. ... . . � . .. . � � .... . , ... ,_ �:._ ..... . .. � #� ����'.����} � t , -Contractor � Dxte�� � .. . . .. � . . . . � � [am exertpt from the licensing requirements as 1 am a ' . �I' ' 3 d rj� ' � ��� , �.� i licensed a�ch�tect eir�e-Yegistered:professionsl�.engineer P�aR Ch2Ck f08,25°(o Of 0bOV0. � � . . � � � � -i. �. �' acting�in my professionat capacity(Section�9051, Bus-`�� � �� � � � � � . iness and Pr�fessions Code). PERMIT►SSUING FEE$�p �,� �`��'S Q�' � oa:19`=a3 ' Lic.a�Reg.No. Date TOTAL FEE Q � � ,. .....FiOME OWNER-BUSLDER DF,CLARATION � ' .... PLAN�CHEGK'APPCICANT..,.,..:. �..... - . .. .. . . . .. . . . . . _ , . � � �I�here6y�affirm.that.t:am-exempt frqmr the.ContraMoi'a NAME �. a N- . ' .�'�IC�' .. . . , � � , � License-Law for Yhe following�reason (Sectipn 7031.5,Busi-�� � � � . � � � a . �ness and Professions Code): . �� � A�DpESS .D,"f' f�./r,7� _ ���: � . � � .� . ...� j � ��I-,es�owner�.of[he ptoperty,�will do The�work and the � .. � �9��f - _ � � � � �: � �structure is not intended or offered for sale�(Section C�TY � ���L,� ,TEL.'hf0. g,�r�y . . . � d -, '� � 7044,.Businessand�Prafessions.Code}. �� �� �� � � � ' �,I � OWNER � . - � � � . � - . ) �� I,as owner�of the.property,�am exclusively contracting.. � � � � � , � . � � , .with.ti¢ensed eootra¢tors to construd �the�: project MAIL� . _ . � � � � - � . � � � � (Sectian 7044,Business and Ekofessions Code). - � � . 1�PDFIFSS � � � � � � �. - �. - - . . . . � ... : _., _ .. . . . .. j . CUNSTRUCTION�LENAINC AGENCY � CtTY- , � 7EL.NO. , � . , i ... I heceby xffirm that there is a cunsVuctibn lendi�ig agency--�� �� - , .... � �� - � : for the performance of the work far which this permit is CONTRACTOR .� - � -��- � �� . .. . .; . . ..,. ; � issued�Sec.3097'.Civ.C.). ���N�, _ _... :.,. . � 4ender 5 Name .- ....-... ADORE55 . *,,.�. ........ ... . .. . . , . . .� . . . ........ .. _.. ... �;. ,. Lendeds Addresa � � � . }' � . . � CITY... . ,,.. ...... TEL:.N4�. . , '.�. _ .. . .. . . � � � . . � . . ...,. . ._ . _.. _¢ _. ._ . � � 1 Certify that 1 have read this applicntion�and state that the� � STATE� � �'�LIC.� - � � + � . aUove�intocmationiscorrect.lagreetocotnply.with.allCounty�-,-� �ICEN6ENQ � -��� -���GLASfi -�. � -.. . . � ,_, ,y„ _ ��. �ordinances and State laws regututing Heating,Yentilating and -. - � � . . � - . � � �� � � g� �� �� ; �. Air C�nditioning,and hereby auihorize:representatives of;his . ���_SEE AEVERSE FpR�EXPLANdTOAY lANGUA.GE -��-� .. ... ,...,.. . .,.. .. ,�, ,. . � .. '' �-Cuunty to enter upon the abave-meniioned property�fpr . �� � �� , . � � . � .� , �- , .. � - " � � . ���. ,� ., ins e n oses. . .� ��� '�� .. --,., ., . ...... .. . �.: ' , P ��c. 9 _ ; s -�. ' nature of Pertn'� -e� � .�Date .. , . ..... , ,.. . �. �. _�,.. .....,� ..,_, .... � :, � . . . -..�. . . . __,._ .._ _._,.... .'.._..� i � � � � .. � ' .. ' . . . . �. -.. . . i s.�- � , . � � INSPECTOR'S NOTES � � . . . � � , OWNER-BUI].DER DECLARATION � � . . . . � . � � . I heceby aff'um[hat I am exempt from the Contractor's � � � , � . License Law for the following.reason/Section 703I.3, � ' � � � � - � � � . , . . . . . Busteesr and Proferslons Code/: Any ciry or county ; . ; `_ ,., r,_,,. �, ,�� � . . - whlch requtres o permit ro conarruct, alte�, rmprove, , � • , '�,<-� ��. . demoGsh,or repai�any structure,prior to its issuance, : j ,� , .,�,� ,` . ... . . . . . . also�requtres rhe�aPPlicant for such permit to jife a , � - � � �"' - . . � . , signed atatemenr that he js lirensed pursuant ro the . � proviseans oJ�he Contratror's Lreense Gaw(Chapter 9 . ..� ., .. cx . .� \ � �' . , 4�,� .� � � �,t., � �;,. .._�� . . ' t.:ras;4�.�� ���C'�"' �' . _ . (commencing with Section 7000/.of Dirision 3 of rhe � ,., �1 �,�, � - Businesa�and Professions�CodeJ or thut he rs ex¢mpt ; . - �herefrom and tNe bnsis jor rhe a!leged exemptinn.Any ' � .- � . , � vfolation of Secrion 703I.5 by any applrratt for a permit ` �� � ' � '�- - � � � . , � . subfeUs rde trpplicanr to a crvi!pena7ry of not more rhan � � � . fiJe h:rndred�dollars/$S�QJ.: . � � , \ - . _ . . . � '""{�I�•aa owner pf.thgiQro�erty will do[he work,and - � . � Nte ru�ure s�,not ntended.oibffered for sale. st a[ i 4 �' - - ' � �' �� � � . (Sec..�044, Btrsiners and f9ujessions Code: The Con- � � , -�� . � � � � � � � � lraetor's Lrcense Law does no�apply to an owrser of ' ' - � � '� . propeny wha,builds orimprover thereon,and who doea ' ' � � such Work himrelj provided that such improvements � � � are not rnrended or ofjered for aale. Ij, however, the ' ��, � - buildrng or improvement !s sofd wlrhin one year oj ; � � �,�,�,+ � � .y. rnmpletion, the�ownervbuifder wil! have !he burden � � of proving that he did�no7 build or improve jor rhe . , . � ,, �• . . . �. Aurposeofsale./ . .... . � [] I,as owne�of the property,am exclusively con• � � � «, .. � [racting with licensed cont:actors to constmc[the project . � � � /Sectron 7044,Busrness and Projessions Code:The Com � •_ � t k . . . . tractor's.License Law daes not apply to nn owner of �� ' � . . property .who buildr or improvea thereon,�and who . � . , , i, , . coqtmcts for such projects wirh a contractor(s1/icensed � � � ' .. � � . pursuanr ra the Contracror's License LawJ. . �� '�. , ...- � �. „ . - 'Li t. y1y._ . .. . , , . J am exempt under Sec. , - ' B&P.C:for this reason .�_.. . . . � „ � .. t L:'.. ':��. `�-._ \`.t•�1.�_ � � � � . ' � � �V �. _. . . ♦ . � �. � .,���a,-� ..__. ' . ' • ': . 1.. ,...`� � r �': ,_. .l♦ � l . � ' � , / - : �. ....\� �" Date ,��., ;'.', � Owner � INSPECTOR'S NOTES . :.�j^-.:r...r:.i,,,� r..,,,,,*..y�.:,k � . ., . �. . . . . - . � .. , . . . .. .-.�h ,. 't . . � j ���. . � . . . , . ' ' � � � � - ._, .... -. e . :� . , ��. C � `>`�- i� `'ti J' �`i y . ti .`u