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HomeMy WebLinkAbout1804A (10) 76A364C l4'OIt1:Ef4S'COAIPF.NSATION PP.CI.ARATION �E-B,E,Z.ao> �A f��P L iG�.Tl O f� FO R P E R t��IT 111��� � 1 hereby aferm thai I have a'c�rtiPicate of consent to self � � � � - . • � insure,or�acertiCic��enf15'orkcrs'Compansutionlnsurance,o'r HEI4TIN('i-VENTILATINGAIF� CONDITIONING a certi('�� therrnf(Se��.3600.Lab � �5' � ��,,��Ia8�3-��y� ; �i cort�ri�d copy is nertny��rnisned. COUNTY OF LOS ANGELES BUILDING AND SAFETY I, L� Ccrtificd copy is fi1zJ«'i[h the county building inspcctinn FOR APPLICANT TO FILL IN E3UILDING ,` department. . � qppREss 3�h1 _ Uate ppplicant IPRINT OR TYPE ONLY) � - /�� � - — ''� � LOCALITY/!/ ' � C1:RTll'ICATG-OF LRIiJ11'TION f'R011 R'ORKlKS' NO. TYPE OF APPLIANCE OR EQUTAMENT FEE N(/ CO\1PGKSATION IVSURANCG NEAREST ' � } CFtOS�ST (711U SCCtlon fICcQ IIOf �C COm�ICtef� lf the \t'Otk ItIVO�ve� A6SORPTION VNIT,BTU � � , � Uy �Lc permit is for one hund[cd dollars (5100)or Icss.) � oisraic�r�a . � vnc!esseoev V I certify th�at in the perfurmanee of the�cork for ia'hich[his AIR HANDUNG UNIT,CFht n ��d I O permit is issued,I sliall nat employ an5'p«s����uny manner oS P so:is to become su6jact to the��'arkers'Compensatlon Laivs. BOILEFi,6TU qpp�OVAIS OATE wseE�OR'SSICNATUA[ U Dale Applicant COMPRESSOR.6TU— I � N ROUGH / �jf NOTICF.TO APF'LICANT:If,nfter making this Cer[ificate o( VENTILATIDN SYST[M FINAL �� '��'�(�'(�' _� Z Gxemption, you shnWd become-subject [o the N'urke�s' ���— � Comprnsatinn provisions of the Lahor Code,you must£nrth� EVAPORATIVE COOIER - � � ��� VALIDAT Ji�l � � � � �vi[h comply wi[h such provisions or this permit shall be � deemed revoked. , FURNACE: FAU—GRAVITY � � - � �� � � � � L[Ck:NSISDCONTRACTORSDECLARATION PLOORr 6TU� I � 1 herehy affirm tl�at 1 am licenscd under�rrn�isionsofCha�ter � HEATER: SUSPENO[D UNIT- � � � � � - � -� � 9 (cnmmencing with Seetion 7000)nf Division 3 of the Ausi� LVALL �, � ne.s and Pmfessiuns Code,and my license is in full force and � . , . . �, . . . . . . . eCfect. f���//�l � —,/ .� _ _ �__U.,� ,��� ' , � Licens/a NumF —!�i' �ia Cluss����1� .. .. . . . . . . . . . Con[f Date_EJ=��_O_ -- - — ' - - . � � � I um exemp[ .rom the licensing reyuirements a5 I am a - licensed architect ur a res���ered professional enginecr PI3n CheCk(ee 25°0 of dbove. � � � �. - . - ... . . .. . ' ��t���F t� my pmfession�l cap�city (Scctiun 705�. �uv pERMIT ISSUING FEE$8 Q ' � iness and Nrofessions Code). � ' � � Lic.or I2eF�No. � Uare TOTAL FEE �� ' � I10>fE O�\'NER-DUtLD[R DFi(:LAItATiON PLAN CHECK APPLICANT - � ' . � �taauF � � hcreby aTfirm rnat � �m exempt trom �he Contr�ctor•s Nahte I � , �ro 8 � License Lax fur thr fullowing reason (Section 7031.5, Rus� ��, � . . nesc and Professio�s Code): ADDRESS �� � � � '� �.�.��r 1 3 5 0 � f, as u«•ner of the property,w�ill do thc�rork and [he , _. „ � . � _ s[ructure. is not intended or offered for salr (Section CITY / TEL.NO.� . E��"a i( �j,5 Q�; ��7034,6wineu and Professions Code). '-'-'L=r/� '���,{ . . . . 1 \ f,as o���ne[of ihc propetty,ani eaciusi�'eiY contractin5 OWNEF � ���/` ' '. 'r[I�1��F 8� wi[h licensed contrsctors to con.sVuct the proJec[ MAR �- �C�"D�-� �. (Section T054,IIu,siness and Profes5ians Codc). AD�RESS � . � CONSTkUCT10N 4ENUING ACLNCY CITY _ _ _ . ��• �� _�'�/�'�,�.. �. . I hereb� affinn that [here is a cunstruction Icnding agency - �fy� ' ' for the perCormanee f [he worA for ��h�ch th�s �+rrmit is CONTFlACT /�/y�''-') �� �� �� � � �� - . i sued�See.9097.Crv.CJ. �-I!t�y'`�! - ��� _ . . . . � . . LcndrrslJame AOD�IESS /A ' ' '. � - " " {� �� � — �..' Lender's AAdren ��y}��. _'7"�_ �i ._ 7GL.N���J� . . _ .. . . . .. . . ..�f GLn(.iYI(�j�/ / 1 certify that I ha��e rv�� Ihis aCF�icati��n and state Ih�t thr S7ATE pLIC. � abovc inform�tinn is correct.1 agree to compl>�with ali CountY LICFNSE ����17 CLAS" �G��� .. . . , . . . . . .. . � nrdinances anA Slate I�ws reRulating Hc�ting.Ventilating untl . r . . . , , Air Conditioning.and herebY:�u[horice rcPresenta[ives nf this SEI:Iti;�'L:ItSES 1'DIL gXP[,ANATOR}'LAM1GUAGF � .. . . ._ . . ... . - . County [o emer upnn [Ire uLuve�mrntimicd pruperU� fnr . � , i�iti��' fi ��Ut(�PSi's. . .. , ... .... .. _ r��_ _' _!�'�� � Signatureoffkrmittee Ua[e . . . . _ . . ....' � � � � � INSPECTOR'S NOTES 01NNER•i3U1LUEP.DECLARATIDN � � � � . � -'�`I�hereb}"affirm tliat I am esenpt frtim l�c Contractox's ' � . License Law for tlic following rcaum(Srcfion iO3L3.'� � � � � - � Business and ProJesrions Code�: Any �ify or courrry . � whlch requires a perrnt� ro cottatnrcr, after, ir.tprore, "' �' -� � � • � .� . � � demolislr,or repair any strt�crure,�rior ro Rt i.csuenm. - � - � also requires die app7icenl Jn�such pennir to fife a . - � � � , � � . sigrted staremen� U�at He ir lrcensed pu�suant to tlre - <��;'� � , provisiona of the Contra2lor's License Lew (Chapter 9 " �. .� ' • . ., _ , ,, ..., _., � (eommenririg x�iNr Sertiors 7000J of Dh'ision 3 of t1�e � - - Ilusiness arrd Projessions Code) or dmt Hc rs ezempt the�efronr orrd Jite basis for�pe aReged ezemptiorr.Any '..� '� • � vio(ariora of Sccrian 7031.5 by mry applicanr fora prrrnir � s:�Gjec7r tke applicerrr m a ciri!penair}�oJirot u+ore rJmn . Jire fnaidsrAdn!lv�r(SS00J.: � . ❑ 1.as o«n,•r of tl�c proper�y��ili do the n�orA.and ' � - � � the s�ruc[ure is not intended hr ofCercd Pur salc. - .. -�--- - . _ . . \t - ., , . (Sec. 70d4. Bu.riners arrJ Profesxiuna Code: Tl;c Coro- . - � uactor's License Icw does irot appfy� to a�r ox�iter oj � � � Pr��Perr}�who build.c or inrprores 7lieremr,end K�fto daes , � , � sud� work hinaclj prorided Nrar sudr i�rzproremrrur _ are not iirtended or offered fo�tale. f�. huwerer, 1he , building o� rmproremerir ia sold wid�ia one year o( � _. - completiart, rlie nwnervbuifder wif7 hare the burde�i '.-r �• . � Of pvorirtg �l�a� pe did no� build or Drrprove jor fitC �i � �;�Purposeujsolc.J . .." .. � .'�Q 1,�as qivncr ut[he property:am csch�si�•cly com .. --------.-� ' . . ��� . ' �,traeting.witL Iir,�nsedcontracrocstoconstrucLtheproject �r � � ' ���S�ctiort 7014,-Busnres.c a��d l7ofcsrionr�Coder TGe�Con� . riacwr's Lirense Laiv docs r+or app(y ro ett ox'ner oj . . � .property wko Luifds or impro��e.c rde•eai, auJ +.�ho ;.; contracf.c for sud+p�oJeCts wiflr e miumcfor/rJ lirensed � . � - ,�.�: - pufa�em�t ro d�e Conrracror's Licerim Lew/. . _ . .. . .. , .. . � , .J�.�,,.,k . ., . I am exempt imder Sec. [3 cC P.C.for[his reasan Datc � � Owner � • �\�'�-�� , � INSPECTOR'SNOTES � � - �- -�- - _ . - ..' - � �, � . .. � _ '--- .� ., - _ . ._. ' . .� � - `t , . .. _ - .. . .. i. . - , . •