HomeMy WebLinkAbout1777A (10) WORKERs�oMPENSAT�oN oE«ARATioN� APPLICATION FOR PERMIT �
I hereby affkm that I have a certificole of conseM lo self . . O(i�
�„s�.e,oracerfificofeofWorkers'Compensation�os�ro�ce, HEAiING - VENTILATING • AIR CONDITIONING G �3 ti
or a ceriified ropy ihereof(Sec.3800,lab. ) 76A96aC �
�7�e� � CE+BIBIREV.10/81) . . . . � d
�cY N �'���Y, . .. . . . - �.
Certified copy i:hereby f�rnished. COUNTY OF LOS ANGELES BUILDING AND$AFE7Y
� .Ceriified copy is�filed wiih rha coonry building inspec- �/ FOR APPL�CANT TO FILL IN - auno�Nc � /� v
q (PRINT OR TYPE ONLV) ADDRE55 �lD M�m'M'b A"'
tion deparlment. J L � '
' Date � � � / Applimnl- j��'�� �u� L�l NO. TYPE OF AVPUANCE OR EOUIFMENT. - � FEE ���ITY ���yy�� �rr C 30
CERiIFICATE OF EXEMGTION FROM WORKER$' NeneEST
� COMPENSATION INSURANCE cRosssr. H n hv G�vtf /yL
. (This setfion need no}ba eomplafad if fhe work Involred by ABSORPTION UNIT,8TU nrsreia rvo. vRocesseo er
� tha parmif is for one hundred dollars(f100)or Is�i.) � J
AIR HANDUNG UNIT,CFM /U (/'j
I�tertify Ihat in ihe Performance of the work for which�his ! �
permit is issued,I shall not emp�oy any person in any manner BORER,BTU
so os fo become subject b�he Workers'Compensation Laws.. _ aaacovats DAiE �NS�ECTO4'S$iGNAfURE
�ate Appiiconf ' COMPRESSOR,BTU / ROUGH 9��y� ��,
W" E TO APPLICANT: If, afler making fhis Ce�tificote of VENTILATION SYSTEM � 3�pOy 1 �. FINAL �p.,�y1. ` .
E. �Iian, you should become subjecf fo ihe Workers'
Compensation provisions of the Lobor Code,you musl forlh- �rpppRATIVE COOLER VALIDATION �
winc �omp�y wiih such provisions or �his permit shall 6e �
• deemedrevoked. � � .. FURNACE: FAU_GRAVITY
- LICENSED CONTRACTORS DECLARATION . F�ooR BTU �
I hereby affirm that I am licensed under provisions of Choprer 9 . HEATEa: SUSaENDED UNIT� ,
`(commencing with Section 7000)of Division 3 of the Business ' WA«
ond Professions Code,and my license is in full force and eifect.- � "" pr,
2 � eL.:_�C W :�1 7 Z 7 A �
Litense Number f Lia Closs��/ � _ /�_; �� . d� , n• • • • •$ a, I
. �� �!.` �� Dai�J�. p_�G-pj / Fr^�[U-0 . . O
CoNroctor / 1 + •8 3,5 0 �
❑ I om exempl under Set. . W
Plan check fee • • •3 3 5 0� y
8.8P.C.for this reason�
PERMIT ISSUING FEE S �� S 0 9 1 6—8 7 �
Date:
Signorure TOTAL FEE g�j sC)
OWNER�BUIIDER DECIARATION PL.4N CHECK APPLICANT .----- �
I here6y offirm rhat I om ezempt from the ContmUor i License�� . � � -
Law for the following reason(Section 7031.5,Business and , NAME . � - �
Prroiessions Code): . � �
l _)I, as owner oi ihe property, or my employees wi�h Ao0RE55 ,.r_
ages os their sole compensoiion,wi11 do the wor:;ond C�n, r� TEt.NO. �
the structu�e is not tniended or offered for sole(Section �
7044,6usiness and Professions Code). . .. OwNER � 1
❑ I,as owner of the property,am exdusively comrocting
r[ �y •
with licensed contractors to tonstruct the project(Sec- D�RESS t� n r' �
- �ion 704E,Business and Professions Code). � �
CONSTRUCTION LENDING AGENCY � CIN � ti� TEL NO. G! -�
�hereby affirm tho�there is a cons�ruction lending agenty for �
the periormonce of fhe work for which lhis permit is issued� � �pMRA[TOR� � � �n �� C � ,.
�Sec 3097.Civ.C.). --- �- - � . - . . .
- ADORE55 O {r.L� /YI!+L -. ... . ... . . . . . . . w - . . . .
Lender's Nome �7
. CITY 6�0� . TEt.NO. . . . �/._ ..��"�� '—Ay� � � ��
Lendei s Address � /��D , '��•-_ ^��'�''�"�{' ""'
STATE � . LIC. �.r /� V
I certify that I have read ihis application and state that the- LICENSE NO. � CLASS� ✓ . . .. �
. ..._.. _.. . .. . . . _. _.
o6ove informalion iz cared.I ogiee lo comply with all CovMy q,� � L �n n- - ,
ordinances and State laws relating�o building mnstruction, . .. _. _ . �JI'7�r�'t'� ��+-tt/ c✓w
and hereby aothorize representatives of this CouMy to enter ' ._ - � �
vpon the abov menlio�ed properfy for inspecfion p�rposes. . � � .
SEE REVERSE FOR EXPLANATORY IANGUAGE ��, ��d
q-/G-�?�
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