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1466A
i , _ � - � -WORKERS'COMPENSATION DECIARATION � � � �� APP�IR�/1TIA/N �FOR ��RMIT I � '��, � I heieb affkm that I have a tartificate of consent to self � � I y - HEATING • WENTIIATING • AIR CaNDITtaNING insl�'e ar a cerLficate of Worka�s'Compensation Insurance, -- � r [tif(ed tbpy ihereo Sec 3600,-1a6.C.) ` ���� � � ,`�W$$�3� 1�.9� C�SMLlnls�o�.�s cRe, ,ae,�. , .. Polity No. Co pony� . . . . . � . .',. , f""3 .. � . �- � -CQUNTY OF LOS ANGElES . , ..- �. 6UILDiNG AND SAFETY . �4��(Cernfied copy is hare6y f�mished.- ��� . . . . . 1 i ��jfI Cer�ified copy is tiled wi�h the a nry bviidin ��:P fOR APPLiCANT TO FILL IM � su���in,c ��/ /� � �/� 'Fion de arfm� � .. ' ADDRE55 � "{� {..r Q.r '�i � , (PRINT OR TYPE ONI,Y�� Date "'� 0�-� Applicant. � . � LOCAUtt ` � - .�NO. TYPE OF ApALIANCE OR EQUIPMENT"��� � � FEE � � � CERTIFICATE OF EXEMPTION P OM WO� ERS'. . NEAREST � ( �( �. �� �� CtlMPENSAtION INSURANCE�� ' . � � - �� - � � � . � � �� CRO55 SL� � �1N\CIlb �(!�' 'fi L'J�h{f '�.. _' .[Thla�eefion need'nef 6e eompleted lf 16e�work involved by . AB50RPt�O�v UNR,:BTu � oisrcicr No. veocesseo ev �; the perm(t��for ene handred dollan(S100J Of Ieas.J q�R HANOLING UNIi,CFM ' I cerlify that in the performance of the work for.which this . . . . . � � ta ����� ', ' permit is issued,�1 ahall nof employ ony peraon in trny�monner . e0itea,BIU - , �'so oa to become s�bject to tha�Workers'Compenaat�on Laws.�. � nrraova�s DATE MSVECTOR'S SIGNATl/RE - �� ', . .� . .�;.. � , . .. . . . . . .O . . � ; .. �_ � . � . .Y�... ROl/GH . r I Dafe � ApPliCdnt � : . . COMPRFSSOR,BN . . . ... ►J �� NOTICE TO�APPLICANT:If, nfter moking.th�s Certificate of VENTILATION SYSTEM. . FINAt � . � � �Exemptlon, you�ahoutd'6ecome bub�ect 10�the Workeis'_.. - � ! �� Compensation provisions of Ihe Labor Code,you�must forth- . . EyqppRAAVE COOIER � - � � VALIDATION � � I . I, -� with comply�wiih'auch provisiona or�4his�permi�ahall be � � � • deemed Ievokad.- . �� �- � ��� �� ., � .� � � . pURNACE � FAU �_,.,�_GRAVITY�� #��/'��� ' � � �LICENSEO CONTRACTORS DECLARATION f�oOR � �Biu � � � y i . I ' ... andrProf s'slo'Gode,�a�m�a nsees m fulliforc and effed9.�.. � HEA ��NDED � Uw7— ."_" . . . . � bY W P � � ��WAtt� ' � 'commencin wSth Sedion 7000 of-0iaisfan 3 ofihe$usineu ' � � • • � �.Q�=i . Y � ' . . Y . . . . _ ` . ._., . __.. .. . . . �£, I � � ais� Q(}Qc'I O I ! License Numbar ' .' s �+`` � .: � � _. r . .._., .. . F19�0 8—8$ � y I � ic.Cias � _ ` sr u cr ' p' { � ; ' Contrcctor pafe .��'.. . . . . . ... . .. . .. . . � , � i ❑ 'I am exempt�nder Sec: � � � , . _ . .... . _�� . � � � . . . �, � I . Plan check ee ` i �, I '. �" 6.8P.C.fo.rhis r on ' . . � . - -- PERMIT ISSUING fEE; � I Z f e: �O � I � Signarura S. TOTAL FEE < �'j , ' � .. OW.NER-BUILDER pECL RATIQN���- � PLl+N CHECK APPLICANT. ...�.� . � � � i I, ; I hgreby affirm thpt I am exampt from Ihe Cantroctor License"��""� � � ". � . � � '' Law for tha following reason(Section 7031.5,8usiness ond NAME � :'"'�'�� � � � � ► . �� 4�1 Jr" {� I ; �� .. Prokssions Code)r - . ��. ..'. . �. .'.� .......` � � ' � ❑ l,,as owner of the properfy, or�my employaes with � ADDRE55. ��'�„ - � � - � � �• � • • •8 � . � � �� � �� wages as+heir sole compensa�ion,will do fhe work and CITV �—� � TEl NO. � � (�+2 Q,�]5 i . the slructure is not Intanded or affeFed for sala(Setlion � . . � . � 704a,Business and Professians Code .� ..'....... ' . �jr�..'. .. ... .. - .. .�. ., ... . � .. _ . ..._ � ��' QWNER,�{G/ • � - � •• �PZYSt=.�� �, Q I,as owner of the property,om ezctusively contracting � � �� - with licensed contractors 4a construct the project(Seo / ' . _...'. .... �� -. . -�ifon�9044,Business and Professions Code):.. ... � DDRE� � l� � �- . � . . . . �9�Q 8�8 8� �.. - . .. CpNSTRUCTION LENDING AGENCY .�� �� �Ry. ...- ar�;. -.t��:No;-� -•.�, , , I - �, !hareby affirm thot there Is o�construcNon lending agancy for - �, �� ! the performance of ihe work far whlch thia perm(f Is issued-- �� �pryTRACTOR�� ��'r`� ''�," '��� p � . (Sec.3097,Civ.C.).� � , . . � � . _.... . .. .__ ._ . . _.I �. l 1 . .. ,aooeess _ Qj � ,._ _. �, _. � � � Lender'a Nama � " � '. . . . . � � ..... .. EIN ,, '� ... .� -. .. ?EL.NO, $+.�.1.. .. ...,_.... ..........._ ... .... ... .:.. ._._� �. Lender's Address � � - � . 1<ertif rhm I Mave r�ad th�s a liwrion ond srata rhar�the... �ATF y Q .u�. 'p _ _ . i Y . PP � tICEN5EN0. �� �f 6-� tLA55:-. A`.�. .. . , _... , ...__ _... .. . ._. .. .� . � - abova infarmation is rrect.l agree to comply with all Counry . � . � I �� � '" ordi nces and Stat laws relating to building constr�ction,,.,_ � , , .. ._ �„ ' ,. � � � ' , ..�..�`�pnd reby�aothori repr entatives of this County fo eMer , �.... .. ... � . .. .. � '. .�... .,. ...� . .. .�. ihe ab ve-m ion property for in ection urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE � s'�,? �� ._ _ _._: , � ' Signature of�Ap0lic t dr Agam � . DeM . . . � . �..�._- ...... . �... . �. ._^.. . . ..... _...... _.... _. ..... . . . ... .... ._.. i . . . �. . . . - . � . � . . , . . �. .. - ' � . I - "-�� x . �T'� . . . � , ._. , i. . . ���. , . . �. .. .. . � . ,. . ... . �. � . � . . . .. . . . � � . tr- . .�� •.t � , .. ,. . . �.. , .. . . . , , �.. i.. . ., . .. _ .. ' : '?'°_.'",,.. '�' �. ', - � � ,'; INSPECTOR'bNOTEs :OV41NE(t,BIIILDER�ECLARAT�dN'� � -G�hereb �6#Irm ihCr I��dm ex 9'ffr !� /� J� Cl ..��. S + ". . . �' � .. � „ .c:;,l v�.( - � lt � p. om fhe Coiifroctors � ..-..-- � _...._. . ,y.� ..... _ ._...,._ ..._ . . _ ..,.._. __. ... 0 8tusinessL ndProf ssl�Bns'Code)�Anyclty(oCc'ovnl�w3hlc ' ,.. _ .... .._ ..._. � ..j� �. �y r ,/j,� }�'�"y C .�..' . �`a . . h -rAguire's�u`pdrmif to con�/roct,alfmr;,imp ove;:demob56, .. ..__ ____ _.. i p � ---j 5� eK repalr artY trueture pNor�to'ffs I�c uance�.also re �t„��, 1'� � �'G'� ) � i i, n �:�:i. . - ' ` +..74+��Cs jh9 qppl��t tor wch PerM�t fo flfe a slgned sfate- --.�-�il" � � � ! + � ^1 � / . , � i �''' � me��y+hq!heJs�konsed pursuan�to Ihe p�oNsions of ihe _ 3 'y 3�.�s I-�jS��'y.f4 _ ,� �.r nr '.�f,� � �� -- � . Conir6cfors:Lkense J,cw,�Chapt�r.:9(commencing wlfb � �,', ,.... .�.., . ..,... . ,}.... .. ._.... . � : . ' ' ". . � .._ -,!... .. I -.. �'�.:•,: + �1�'` Sec/lan 700o a Dhcan��r Qf tae„8usiness and Prqfes- � . . . . r : y. ^ , __i A- , 7031the4 alle edpexem�exempl iherefrom and ihe�Das7s � ( )4 I „ � _ � f/on An �Glolollon of`Sectlon � � � f . �. _ _ r � Y P Y PP P !t su6�xts:the app6- . . �,.� �;,. ., . ., ��,,::.,�... i i ..;., 1" .�- . . ,:. -- i.,,., � . ;.�.cpnr roP.4!YII peoalty.nf not,moce.ihan f�vo�hundred i . . „ . � . . . . . � i_ � . ._ --i --_... __.. . i - � ���' .: �., �' �. dolfars(S500J.: - . ��=` �-"�" � � ""� � ❑I,as awner of ihe roperty will do ihe work,ond !..._ �_' "_.._.._ . .�..��. ..._.�_... _._. ____ � ._� .�.t' '.�' ' __"' ......�_ . ._ise s/7W4r�us'not inhe��d�r of{ered�r saTii'Cpnfrac- ,,.. . .,. �� . ,: ,,�(ec , ,sinesson „-rpessions4'p e.�� e ' 'i...�. (:,tY.��.,r e 4 .. ' . .. . _.� , .:,. . . �. _ ,_ � r ..,. .,., -- � �-,;for'sLfcenyeERWdoesnotppp�y,�o,anowner,ofproper}y . , _,,,.___�__ " .,�� .:.4vht bullds�or;7mprove�.fhereon,�.ond wFro�does.�such .____ ._._ _..__ . � � : + ._.__ � . _�.��+ ��������i, work himself provtded thoi such imprdvements�are not � . .-C. i �;., � ': '-- �- � �. �' ��... .. �. i. .,,,:. .._ '._ -.. _.. �.�.�:�_ .._:' iMerided 8r offeretl faY 3ate✓If;-htiweJei.Mhe butld(ng or , . ..._ .__ _ .. �" { �, improvement ls r,o(d WfTh1n one year,olcompleifort;the , � � ..' � -e ; - . . .�--- I .. . -:_ ��'`� i __ �� , ,,��ownervb6lfder wil!have tNe 6urden af proving thal he dtd , '�� ,". . f ..a � �..:, i .r' . . ,; � . . 1� 't'y �prove for fhe purpose of sa(e:)� �+ .�: � ' ' .:�i �Ij. . - r,.. / .._--. j`r�_.��'. a� ..:;� � �I`�: "-�trattt❑a�voas oCw,nerp��J}� p�SRer`ys am exclusively con- j� f � n � {, . . � � . � i, ! . , g' ense`''�pn�atiors t� coostioct Ihe piojact �, ' --- � � �i�5et.\ 44)Busttlbs# r�d,Prpfessl�sSC�d�e ihe Contrac- ��. � : .,. . � . __._._• � ' � � 1 - � ,•�� � :� r ,1 �f �'. for'�S Ctc�nse laxv 8oes jifot:�:ply to on ownar of pr'rqperty � '' � � �''�� '' � "� � whd;6u!!ds or Improves the{aon,Rnd:wlto�oMrqtta(or � __ . . _ . , ... _.. . _ . . __... - - - - ' � � ' �" -�`�� such projeef;wlth o controctor(sf Ilcensed pursuani to . � �� _ , Y � e�_s,�e�f�b4����asatoW�J�. �s � ' '� ` ._.r .:. �r ; .__. _ , -- . �. . =. _ ._ _. .,. . ' '-` '�` ...�am ._ .:,i,: ',, , xempt�n2Jer Sec . : _ _ .. _, t , r., �:' -__. "' '' _ , . ; , r - ��,. _ � � ' � for ihis reason ! � � � , P. . B& C �. ... , r . � i i . , ,, , _ � .._.. . .__ . ._ _ _ � i �""'" . . . . . .: .. .. ._.. ��w ,... �, . . ; , , � .��.- } � .�.. , .,, ,,. ,,., . . . .�. .,__._...__. _._____ .___.._._. � .:. i - , � ._. s.�.' , ate ;.. ,, . < + �- 3��, �•��+t,� r� 1(:, ' ' Owner � � ' � f - - . : � F. ,. C "�a G �r'S"� t C;, f i 1 7�F ..� ' .. I, . ., � ; _.__ . _,._ _�. - �. . ,. ... ._. _.. ,n � , .`"€ 4 �-�"��Ti: f � �' . � '� ra ,,' ; � � . ��„� � � ! "�'fa�J '.. 1L ...-, ` � � -; �- ` . INSPECTOR'S NOTES � _- �� ( � � - " _..J-.� }._!•w .i� ._�! ._.. .._. i� , �. �i'7� ����- t� - ,�. . , . , �i77+J . , -.. _.... ._. . .._ . . , �' '...... ._. _ '._.. ._. __ .: �., . .. .._ ___. ... _ _ . . . �. . ` ,�` ��, �"�. � ��. ..,li. ..., .. ... � I � ., ..__,...�... .._.....,_,.__._....._,.,..._....,._. . ..�...__.... ....,,_._. i � . � !, ,.�, �. , ' . •^,t I�. „ . . �. .._.. _.� , _,.». . � .. � , ,. �?.�+ � - � ,�.T- �`�` y�� t r! � . . ......,... �,i,,.' :�`-�} . .. �� >�5���4�,�1 '�l\ �'�„r� . i :