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0973A (5)
—� sNORKERS'COMPENSA710NOECLARATION � � ,APp�'CATION'�FOR P�RMIT� �� � ��. � ioL+robor a ce 4 co'�e�of Worke sr'Compens tion Imuronce�- ' � � � ' � o,o qr fi o yrr,a, � s9AY �ab.c.�. _ �ao�a:+c �..,wHEATING-- VENTILAfING - AIR tDNDIT10NiNG ' C�J! CE•81 REV.10/81J-. ,_ .__. _ _,. . . Pol7cyr l Q �d� - � COUNTY OF LOS ANGElES- BUILDING AND SAFE7Y Cenified copy is here6y furnishe� . , . i �Certified.mpy�s filed with�he cpunry buHding ins ea-. -- FOR APPLICANF•TO FILL IN - Bu�towG ti�n d ort nl. � . � AD�RE55 � ,Y£ f. P��� . �� . . � IPR1M OR TYPE ONLV) . . � /y� � � � D'at� RTIFICAT '�`PplfcaM . . . •� . . . � � LOCALiTY � /��� . . -. NO.� IYPE OF APPLIANCEOR EQUIPMEM� � � FEE . E OF EXEMPTfON FROM WORKERS` � NEAReST � � � � � � I � COMPENSATION INSURANCE ����� � � �� � ' �� � � CROSS ST. i � � � �� ' � ' ABSORPT�ON UNIT,BTU� � � ' (7h1�see�lon naad nof 6�tompiefod if thr work invalved by� . � oisraia No, vaoceueo sv , � � , fh�permN b�for on�_6�ndred dollars(j100)or tess.}_ AiR NqN�uNG uNrt,cFnti - � `O � �. ��1 pertify�that in the performonce of fhe wo�k.for..w6ich ihis.�. . . _ . . � -p'Brmit Is ieiued,I shall nol employ dny person�in dnymanner gpILER,0TU � � '��, sq as to�batome subjbct to the Workers'COfI1PBf130fIOfl�LOW$.,, APGROVAl4 '-OATE � MSPECTOkS 51GNATURE - � :p''. '� �. . � �. �. �� COMPRESSOR,BN �� � �� ROUGH � � � � ate � - �PPlicant .�.._. � �.. ,.� . . ..... . _ __ . . � � ,. __ . NOTICE"TO APPLICANT: If,-after,making �his Certifito�a of� yEM�tAiloN SYSTEM . � � FlNqI - : � � Exempfion, you'should become subject to��the`Workers'... � � - �.` � .,, „ ' ' � �' COmpenaption prbvisions of fhe La6or.Codo-,you mvst forth-� � .EyqppRnnVE CoOiER � . VALIDATION ' w�th comply�with such ptovialons�or this�pa'm�t�sHall be� �� , � . � � � .deemad revoked:�. . . . ... .: . � . . .... FURNACE:...._.. .FAU..� .. � �V � . . ��� : . . . . . , _...__ .. � . � �,. � j � LICENSED CONiRACTORS DEGLARqTION> � � FIOOR BTU . . , � � � i ' �-Iherebyafflrmthafl�amlitensedunderprovisioniofChapter9 . SUSPENDED- � �UNIT -� �� ���"��� ��"" � � � � � � HE4TER: WALL � . � -� '(cOmmencing with SeUion�700Q)of�-0ivision 3�of�the-Business � . � �d Professions Code,and my licensa IsJn full force end eHeo ��� " " � . . ' '� ��� - `--� �--' -�-�" •-��-��-�� � � - � � ;�� - Lice�nse N��urtabar_.�(L�3.LLie.Clnu� �� _._:_. _ .. _..... ..... ` '� , � . . ' �. V ��.. i > � co,�d21o;�28w D.C'.,o�-pEX.�1e . . _ I' � ��� ��� I am axemp!under Sec � .� .._. �--- . . . . . . � � . �y ...� „ : Pfan check fee _. . . N ''� 8.8P.C.for this�eason - pERAlY17 ISSUING FEE� �Q Q 7:3{{ z ' I . . . Dare: _.. . ... � . j Signoture TO?AL FEE #.r.� • •$ � �'- - � OWNER-BUILDER DECLARATIQN ,�� PV+W CHECK APPUGaNT. . � , � � � � . � ����Q,5 Q, - ��� , �t h�ereby affirm thor I am exampt from the Comraetor's lieeose'� , , � � � � . ,- � ; Law fw�he fol�owing reason(Sec�ion 7D31.5, Business and Nnnne��. '' . . � . . � .� �� � . � 3 a�O� � � i � Prqfessions Code�: � . .� -..... . . . . . .. � . . •• • � ; � � I, pa ownar of��ha ro ert, or m�em lo ees wifh � ADDRESS�' . � � .� � � � � � , ��� P P Y Y P Y - � � � O�� $-S$ � � -( wagesastheirsolecompensation,willdothe�workand����� � -� � �-'�� �����' � . �� ' the strudure ia not infendad or offered for stde(Section C11Y �. � � TEL NO. � � � � , : . � - I 7044,BusinessandProfesaionsGode)._. . ."' . -.-. L'']' ....-.---- . '� � . � '. OWN G 7 , . ! LJ� I,as ownar of the properiy,am exclueively conimcting . �� , r with Iicensad contracton-to co�atruct the pro�ect(Sei-:�� ��� - �"' -��'��-�� ''��"�- -"' � � � - � �� 1 - i-- tion 7044,Business and Profdsions Code):��"�' � � ADDRESS . e . . . j � ! CONSTRUCTION LENDING AGENCY . � ��y� � - ���.��: / '� � !�-�? . � � � . � � - � I he�re6y affirm ihat ihere is aSonsirodion lending agency for . � � . ��1�` � � . � � �. iha, erformance of thework�for which this ermit is issued �� - �� - - �..-. ".�.:='' �a . .. . �' �r (SeFP309'l.Civ.C.).� . .P �CONa�ew D. �vf....,:. . ..._.._ ._.. ........._ . _.. .. .. . : �� '�, . .� . � . � ....,..�: .ADD �__. ....,_.. __,.:,. .:.._.�. ... ... :._ __". . . �_ � .�.. ,•... _. .._. .. .. ,' . lender's Name ' . � .. �.�-�-�`. . ; � . . � . . �� . . �CITY. .....,. ' � � � . -.. ... . . .� . . . .. . . , Lender's Address � ' � . . .......'. ..� , . . I ' Y P «���heim :,����r_. ���. s.. �.� , I certif �hot I have read ihis fication and sM�e�hpt the �, ._ .r:�:. . �/�s� : � �OVL. .__ . . ... .._.__ _.. . . _ � obove inf motion is correct.I ree to comply wilh oll Covn�y�� Z 0,��"i � � �� ' � � ' ' ardl� d Staro r atin t uilding construction,. '_ , -:-� � �- � '�. y a�fhor' r f this Covnty ta e �er . .. .. . . ___...'. . .�.. . ___.�. _ _. .. . .., .__. .... ... . . ... ....... ..u� � �� - en' r f )nspectlon por ses�. � " _".� � '� , � . �. '� ,f�,�' SEE REVERSE FOR EXPLANATORY LANGUAGE _ r/d �...�. � _ _ __ ' Siqnatur of p i<an w Agent . .. .. . .Da . .._. . ; .__ ...� .�__ ........ _ _... .. .. .__ ..... .__ ._ _, � . ... .... .. . ........ ; . - ' ' . .. _..... __:.: .. � .. '.�r . , . '. . � . �.. . .�. __,._ '.'.__... _ . ....... . �.. . _-. .. �, . . . .... . . . ' . _ , _. . r , , , } , ,,, `ti `�, ,� ��;;y y, : � � '��: , ,�; ;�` .�� , A��z, � � , � . �. .. , ,, , . . � < .. � , � : . . �:: . 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