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HomeMy WebLinkAbout0501A (4) R'ORKGRS'C017PGV5:ITION DLCLARATIO`J I 76A364C - I I �irrrhy affirm tha� 1 havz a ctrtificale nf cnnscnt to sclf CE-87II(Z-E30) fl('P L IC A T i O Rl� FO P. P E R�ii I i � incure,or n tertificate of�Yorkrrs'Cnmpensation[nsurance,or HEATING-V ENTILATING•l11R C�NDITIONING a certified rnpy Iherrn((Sac.3600,Lab.C.) I Policy No. Compon}• I � �'rrtifird copy is hereby furnicheJ. I COUNTY OF LOS ANGELES ! E3UILDING AND SAFETY � Certified copy is filed«�ith the county buildin¢inspection I FOR APPLICANT TO FILL IN �aui�owc l (` department. � /iODF1E55 �O �� ,,,)V��{ � Date Applicsnt . IPRINT OR TVPE ONLY) /,/� CERT[PICATL OP 1:�li11PTION PIt0�114'ORKGRS' ` NO. TYPE OF APPLIANCE OR E�UIPh1ENT FEE LOCA�ITV D��4,J�^G�f��Juy �� CO?iPEVS:\TION CVSIIRANG> . N'eAREST (T�IIS 5ectiOtl Ilee(� nM be COrt1p�Cfed IF t�1C tl'Otk I�Y(rl�'ed i A�SORPTION UNIT,E3TU CFi055 ST. D � � �..� �L����( �- I 4 h.0 Kt l�y !he permi[ is for onc hunAred dotlan (5100) or IessJ cicrnicn�o. vnecessenev V 1 crrtify th:+t in the(+etfnrmince nf the«�nrk f���vhiCh this � �+�R HANOLING UNIT,CFA7 � Q p?rmi[ic issutd,f shail n��t empiny any prrson in any msnncr i I � � so ss tn become subject tn the 15'orkers'C��mpensation La�+�s. � �OILER,6TU j I - APPROVl1L5 �I�TE IM1SPECTOA'SSIGNATUftE („) Dste .1p(+lican� C0�.1f'RESSOf�,F3TU W _ ---- qOUGH � N YOTICEi TO AVPLIC:\NT:If,ufter making this Ccrtificatr nf V[NT�LATION SYST'eM I FWAL Z F.semption, ynu xhould becnme suhject !n the �1'nrkers' Compcnsation prm'isions uf Ihe La��or Cqdt,'you must farih� � � �s��i, compiy ����n sucn pr�,�-�anns ur �r,�s permit snan t,e EVAPORATIVE COOLER VALIDATION deemed re�oY,ed. FURNACE: FAU—GRAVITY_ L1CLtiSliD COtiTRACTDRS 11I'CI,.Vi:1T10N FLOOR� E3TU � - I herehy affirm 1ha[I am lirensed Uf1,Pf rtbY�SibI150�CM18r}Cf HFATER: SUSPFNDED UNI7 • 9 (cnmmencing�eith Section 7000)of Dicision 3 nf 1he[3usi- LYALL ness and 1'rnfrc•ionc Cnde,2nJ my licrnse is in full foree anJ � �p 5 Q�1 A c(Ct<t. —+f�_��-t't � , LicenseNumhrr Lic.Cl:�ss #�`�(�;i2�2 Cnntr:�clnr Date �I.i �� 'L 5� � I am exempt from the licensing reyuirement5 as 1 am a � Z S O� • licensed architect or a re„istercd profession�l en��nrer �. plan check fee i;of above. f� SQ. ,'.��' ' . actin� in my prnfr:sion�l cspacity (Sectinn 7051. [3us� C iness�nd Profrssinns Cnde).� � PERMIT ISSUING FEE$ � ��.�.3�8 3 �.ic.o�Rc4.No. D�tc TOTIIL FEE � / iro��r.on'veic��uit.urit oect��t�,Tto�. pLAN CHFCM dPFLICANT _ !7 A.�/ /1 l. Iw/� 1 hereb)' a(firm �hat 1 am ezempt (rom�ihe Cnll(f:1CI0��5 NAA1E � p l%v••�- � ���✓ y 1��a ts_K_s dj�,.,_ � I.icense I.aw'fnr the fulluwinR reason(Stclion 7031..5, I�usi- N'" r �j nrsa inJ Nrnfrscinns C:ndt): � ADD(iF.SS,'�.G Z�� • � '�,y�0 3_Cf� �n=�-+-;.,�,—J "-�— -� �if liic yr����i•�IY.��'iii uu iiir wcirk nnil ihe A TEL.NO. �/�I C C struclure��i� nnt intenJeJ or offered for sale (Sectinn CITV _'Li�O��,/— _[f_1� '�Y�-��Y_� � 7044,Dusiness and Profes=ions Cude). � aONlNER 1,as n�entr of the Property,sm exdusively cnniractinG ���- � �vith Iicensed contr9ctors to canstruc[ the project h1AIL /� (Section 7074,0u5inras and Pro(rssions Cade). !sDDFiLSS _�e!_�� _ � CO\STRUCTIDN L1iNDl`(3 AGl:NCY CITV T[L.NO. [ here6y aF(irm Ihat ihrre is s cnnstruction Irnding a�encY 1 � , for Ihe performsnre of �he �vorB fnr �chich this permi[ ic CONTf1ACTOF C.�lOy ��� _��.Q� �/ � . issued(Sec.3097.Civ.C.). � � � / � _ Lc•nJer's N�me ADDRESS / Lender't Addrrss CITY TEL.NO. . . � I ccrtify thst 1 h.n�e ra:+J Ihis:�pplii��iion and st�te ih�t the STATE LIC. ahnae inf�rm:�lir�n ic enrrect.I�eree In cnn���ly w�ith all C<i�intr LICFNSF.NO. CLASS . . ordin�nrr<and St:rtt 1����5 reeuis[ing Hcalinc.Ventil�tin�and Air Conditinning,anA hercby:unhori�c represenlatives of Ihis SGT�:RFSVGRSP:POIt IiXPLANATORY L.ANGIIAGIi I Cuunty tn entrr upon thc abm•e�mentiuncd pruptrty for . , iuspection purpOStS. • • SiRnature nf Permi[tre Date . , . � ...- � � t f - } �, `� �, ^ .. �: �s. - .. cL v� �; .�-. .. c �,� ' , � ' ► - • � ;,� . _� '.� � � .�- � � � . ^ � � , . � - :,> w �- � . _.. ' Z • N ' b � m • a _ • p� •. . N � ' z • � O • � � m � N • N S m n � .. a O . ` S7 N . O � -' m � _. 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