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1006A (5)
_ . . . ._. � � i . � I .. . . . . _._ _...____�. _.�, __..._..�.____._,.-_,_�._...._—_._. , ._......, �.- . ..._...._ r . X,w .. : . . - . . . . .... . . . . .. ._..,_ � ` � .�OMPENSATION DECUIRATION � - � . . .� . .� . ... , �M��b,�_,.,,,,,f�o��tio��a ter�ificate of�,�sa�f,o,a�f APPLICATION FOR PERMIT � insura,.w a certiffcate.of Workers'�fompensafion insuronca,� �.76A3��, � �HEATING -`-VENTILATIMG, • AIR �CONDIT�ONING or a c rfied copythereot(Sec:38Q0;Cab. �.) � ��.e�e�REv.�to/ef� . . . . .. � . � � . � ' . . ., .. .._.. . ��r���..��ompony COUNTY OF t05 ANGELES - . BUILDING AND SAFETY �Certifiad sopy is heretiy furnished..�� � � �' � , '.�'.Cerrtfied Gopy is filed with tbe coyPry bullding inspec- FOR APPLICANT TO FILL IN eu��o�NG .. , tio deparl nL ,� . , . . �. ADDRESS � (PRINT OR NPE ONLYJ .i - Dafe � PPlicant � � . LOCAIIN /� � ; N0. � TVPE OF APPLlANCE OR EQUIPMENT FEE �� ! _� CER CATE F EXEMPTION FR WO KERS'_- �� Ner,kE57 - � � �� COMPENSATION INSU ANCE � ��� � � � � � � CR055 St. . � i _-�(Thls rection nead not bs eompleted if fhe work Involved by. A950RanON VNIi,BiU � oisrRicr wn � � rn ED 0Y . � }he permlt Is for ona hundratl�dollan(5100)�or tess.j � � qIR HANDUNG UNIT;CFM � / ' '� . I certify��hat in the performance of�he work�for which this � . Q � �. I � peripit�i;lssued,'I ahall not employ any person�in any��manner gp��R,BN � � -ao as to 6ecome subjecT to the Workero'COT�79115Qi1O11�OWS. . � ' APPROVAlS .DATE - NSPECTOR'S 516NAiURE '��. �I � COMPRESSOR,BTU O � ROUGH � � �Dcte�� . .. � �-applicant � . . . . .. � � ' � NOTICE.FO APPLICANT: If,�.cfiei�making fhls Lertifi[ate of� VFMIIATION SYS7EM � �, FINAI� . � ](p �V �. Q✓ -�- . � �� Examption,�you �ahould become sub�ect 70�the Workers' � '` Compensariort�pFoviaiooa'of the Labor Code,you'musrfwrh- , EVAFORnTrv�GpO�ER. .. � . �VALIDATION � -�°'with�comply'wi�h�such�provisions-or.this�-permirahall be - ' � . � � � ':�� deemed revoked... .. '� .%-,. " . �: � FURNACE .. ..fAU_GRAVItt ..". .�v� � . � � � - . ' �tICENSED CONTRACTQRS DECLAR.4TION � .- FIOOR � BTU - ��� � � - ��I fiareby�dffirm�thot I orrl licensed under provisions bf Chapfer 9���- HEATER: � $USPEN�ED � UNIT"�_ ��� � �' , � � � � � :( 9 . ) -. of.ehe Businass . '. � wAtl � . _.".-' —. .� commancin with Sectian 7ppp,ofi Drvision 3 occe ond effecL � " ��� � - � ��-- � � -�- � � � � Tq� �LanrefpNumbeCode,ondm Iitense�Uc^Clo�ad:�+� � . :. . .-. -_.. - - . .._ .....� � � � , �/,"/� :�. T '. . .� .� �� dctor -'7��-���ate; , _�� . �.. . �. . . � . � . � . . -� � '�,� : ❑ 1 am empt�nder c. . � �°� �Q 6 A � � _... Plon check fee _ • .d : . B.&.C.for this reason�. . - - � � , . . . #�•.,�.� �8 z ': ��e. pERMIT ISSUlNG FEE S �d � — ' Signature T�TAL FEE O .S�'i � ' �''J a 5� i - .. _ . .OWNER-BUfLDER pECIARATION ��� ��. . Pv.ry CHECx APPIICnNT . . � .� ; .� '�. � �. � � • •�J Q S O c=i i � 1 hereby affirm that I am exempt from the Contrac�or's License� � , , � �, � . . ., . � � tl��4,,,8 7 Law far the fo�lowing reason(Sedion 7031.5,Business and � NAME .. . � . , . � � . .. .Profeseions Code):_ _.__ . ... . � �.. . � . .._. . . . . . � ' . . ❑ l,�as owner of the property, or.my employees wifh AO�RE55 - � . . � � � � � �'�. I, ���� � �. � wages as t#ieir sole Lompensation,will do the work on8�- � � � � � � - � � the srructure is nor Inrended or offered for safe�Setlion ��n� � � � 7E4.NO. � �� , - . � � ,, � . 7044,6usiness and Professions Code).. . .. � -� �� -� � �� -� � �-� ..-..�. .. ...._ .., � � � � � � �.,, - - � -� OWNER . . . - . . . - � �, ❑ I,as owner of the property,am excl�aively mntraefing �` � � � � � . � � � wirh licensed coniractas.�o construd the piaject(Sec•� �� � " ' �� . � � .. � �- �t'ron 704A,B�sinese and Professions Code�. '�� � ADDRE ' '�� � .� CONSTRUCTION fENDING a4GENCY � - -�-�� �iT - � �TE�;�Na� � - � . ; t hereby affirm�hat thare is a conaMuction landing-agency for �, � � � . . . '. ihe parformance of the work for which this parmi��is issued --���� �p�ACiOR�� �� -�� � -��/ � � ' _ (Sec.3097,Civ.C.�. � .-' . �. . � . . . , _._ .__.�.._..__...�_.. ..._..._... . ._.._.. .... -._ ',. - � � . . .... .. . ._�.,. ADDRE S� . .. . . � w... . ,. � .., . .. _ .......... . '. :.,..'. . -. '"c.. ...._. ... . . Lender's Nome � � "-�. - ' � � - - � . CI . . .. .. TEL..NO. _... . . ,�... ..-. ...., . .� .,.._...�'�, Lendar's Address � � � � ��� ' � � ������� � - - - � � i certif that 1 have read this a liwtion and state�tha�the�-_ 57 �t . ���' , , . , ' � �.. Y PP �� LICENSE NO... .� . . �CtA55 .. �. .._... ._ ___ ...._. . __,._. ., . . .. . . . .... .._ _._. above information is conect.i agree to comply with a0 Counry' . . � - _ . -� . ordinances ond State laws relating to bu7lding_congiruttion, � � � - ' �� � � �� � � . and hereby au�horize repros tives bf ehis County to�enter , .. . .. ... . .. . . .'. .. ." ."".-... ..` . ...... ...'. .... ..... . .... .. . upon t ove- ention pr erty fw inspecti n purpo s. 3EE REVERSE FOR EXPLANATORY LANGUAGE . ' __ _ _ . : _, _ _ _ . .. . _ . . _, � . .._ .__ ._ _._. .., Signatore of pliwnt or Agent . . . ��Dd�e . . . . . . . _ . ..�.. . . '. �_. ..__ _ , r _ _ _. _. - � � . . � '�'�: �� � �,�,� , , - , � � " � < < • '� : ' ' INSPECTOR'S NOTES , ���`OV�NER-BUILDEI�'RfCLARATIbN ;' , � : � - a:i��i6're6y`nffir�i ahai 4�am�Axeinp��orp�thb'�onlracto/s � � � � •- - - - �� �- �-� � Licansa Law for.the-fo{I6wing��reasort(SecFIBn 903L5, ' ...` -,' . .. .. .. -. • .... -.-. ...- .,-•.-. 4_ - .,.'."•..^..... Busl ess npd Professions odef Any dty ar munt Ich r n 4, y,'ayl' � `- y - �� , � . requlres a pFrmif to congtruc�,qlteq lmprove,'deinblish, � C' � � , �'n{repair eny';frucfure,prlor,;to�is tssuaT�cr}nlso�e- � f M1 ti � � � i �qotrmsfhee�pllc.onttorsuch�er7,Ir'rok7e'p.slgnedsfate- `tr. ._;._,�.:.�e, �,x..->:.,; s�_ . _ � � . ,. ��,�!".. ..' s ..* � ment fhaT Pe ls Ilcensed pursuvnf to the�prov7efons o(the f, .-.,,,, .a, _t�,TF� ' �� \ ���� � � ' _ Confiractors�l(cense Loy�fCF}op,fer;9-�'commencing with . `.. ` • .,� ._'ty- �_._ ..., ��_..._ . �-'- ��.:�:_ ..����.. � ' �. ' fc nik d�ewed�xem Ho3nmAn�e�oldfl v pd�ScQofes- IA" .. �,,. ,rYC3i.5_6y anyQpp1imnf for;q per,mit s�bjects th�,4asls � Hon --�- , � �.�.... { ,cont�o..a c1vlL�penalty of.not more�tbpn.fi�e huo A+I . , . i_..__.__.� . ___ . • ._.- . . ._...____�, i � , d 1 4 ---_ _ "- --- ,�., _ _. -_ do 5500).: dre � _. � �., _ :.. °', { '� ' � Ilars( � � � �� �.( . ^��; ,�` 1�. -� ��' ' � � ,p �I,os owner of the property will do the work„and , .... A ...- .-� ���� �� - h� ' ' �1"'t c� ' offe d for a�e �_ __. _. __..._ _..__. ..� ,. . �.i � �. 1 e..at�uciqra is n4.,in ende �oi,_ �a . .._s , . �� . ,•. .��r ; - • . ... .�-. ' T .. � , , . ., . ..., � � ____ -�...�. _ ". - L_....... __ .-d � i " ... ., , ,, ,fSec_7d44,�ustRessandPlofesslonsCode:��.TheContrar . ?...... _._....__ . .. . . .. _ . . �, . µ .,.',;:�,(..',.�.:-,.�'; : . , ,,:;�...,- ..�,,:, . �. �;tor's,LlcenseLaw�doesno�ppPly�lo4nowne�ofproperty . _..1.___.....__ 1 .. � : � ,:�,,.�;...who�bullds:or lmproves�..thereon,�..and.who.does.such ;_._.. ...__. .. - --- ...__ .._.. . . � work bfmself provlded fhal such fmprovemenis--ar�not ,� � �... . .,�C" •_...� �,.�� "' .' tnfended'or'afle�ed fotEcle;ff,however,Rhe buflding or ,.....'--._ . ._-_:� .., :-. __ . ..._ . . ' ... ..�- . �.��. � i. � <�•r�.;��tmprovemen�is sold I.xlthin orre,yeor ol eompf§7ion,i the - -�- --��-- �--�-- � � �i °���.:�.ownerbulfder�will haVe the burden ot,provmg fhat he did� __-- �-- . _ ... ..__-_ .__. �..,. � � � �� � � � � � �� -"=�not bblld'o�ImArbve ferdhe-porpose of'acle}-'�� "� �:, ' ' � �. ._. .__ ........ ___ _...,. _. _._- --_-- ;i r,❑I as o '6fih$pcape�W am exdusivaly con- ` � � � ';�� vact�ng with lica,sed�ootratlarslo cortsnuy�the��ro�ecr . . � .,. .. .._. .. .._ - -_. _... .-..._. ���4SSe'�7�t)9us�{ress and,Proles,s�o�es Code 'rh.e CQ�troe- , � . 4 � i '� ' toP's�t��ehselavSdoes��afbpplYfbartP�erofpr4seriy �� ,: ,.. �� , �-�- --- ---- � --- --- ---w� 'who builds or improves,Yhereon,ond v�thq contrqc�s for �:; . .� . ; E 'r` ..:-:�i:, . ..'sueh prolech wl�h a eonlraetor(s)Ilaens�d pursuan�fo y _. i ,_ Y . - .`. , y __ __ -__---iheConhaciorsLfcanseCow).'` ' . . . , . . , , I . . . � . - : , . � . _: _.'�__. : .,-.::_ .. _._ . -._ .___ _- ' ._.. _._ ._..._..__ , ',.. . ' �� : . ,.. J ; ' , '.-.'�"3- I � �. , . . . � �. . .. .. '... _.__. ._.._._. . .. �. .._ . . . � . _ . + .. I am.ezempr u�ider�ec. � .,�,: : . . .,_.. . .. ___ . . _.. _---.. _ . .. . � ,_...�_.�z'�.r�... -,. ,. ..., ; _.. .. _ .� . . :.. ,. .. _ ,., ., � �, . . P.��for this,- :,� . . , �.. ..Q�& reason . ,.,.. . +._.. , .. � .� � . ' �''� ' . �>.. , ., ..... ,:... :.., . 1 � . j - � � ���•cl,p,,, , .. , .. �. _ ' ' _.. . " � ... .-i�l. ., ..� . . . . a,___. ...... _..... ____ ;.. "." : . .. � ,. .. � Date .,_,_ .� ,_ � � � ..._a ._.;.. ..a:i.-_ ,.`;�_._.._..,t ' -"' �...� ., ._. � i i .,.,p - �,. � r , -,� �' , s .a ,.: Ownec �� � �e . . , ,� ,� - , ; � - �'`'„�„��_t.��'i' � � `t ':^-.. . ,. ,t ,, .__�! . . I .. I , ,. ,.,.�... . r •. , ' . ,. .. � . r .. , . . , _ _ �,, � ,� ,, , � , ,,. . . „ . . , . ., .. � ,.�\,: � .:.:s.��1 � e .�ti.L .� ._:".{ . � .-.: � .. -.�-��� .. . ,.,..,. INSPECTOR'S NOTES c.` , .� . ' � , K�����, 's r__.s � .1..�� ^S.� ±:_ "'.1. ` � ' � _-- _.,, , ; � ti l - � ,. . , Y — _..'_.___._ ....._... __.._. __.._ \ . , �, ,. .� ,.. � I_ ...A`,..a '..;..Sy. '.�_ 'r.�...7 � _ _ _ _..... . . � f. . ..__ _ ....: ".. . ._- '" " � �c�- r�� '��1 v f _.. f�, .. . . .. .� . .. � . . .., . , � .... ., _ .� `, � .,..,.,. ., :...'"„ ....�_,.._..... ..�..�_;-.,:....�_. ...�,.�.._ .......,.'....... . > '. , .. .. . . . , . r.r� . ,,, . �� .. � . . �=7^. .,_ - i . .,. ._ ``Y, ..,, ^�:r R .'� �'y` ��- �.. -