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HomeMy WebLinkAbout1815A �� ��'0126LR5'CO`•1PF.NSATION DLC[,ARATION 76A3G4C . � � hr�rf>} �«,�m ��„� , �,�,r ��r«,f;��t� of���5�,,, �o s��� �E.at8 cz.eo� A P F'L IC AT I O N FO R P E R FJ1 IT ins�rc,or a certi(icate nf\Carkers'Compensation Insurance,ur HE��TIfYG-VENTILATII�lG-AIR CONDITIONINC.+ a cer[itied C�y tphe�reof�()Src.3800,.�i����� � �I��ul"c)'i`����1..7�LY�mpan�. ,'. �I `�I Ccrtitied mpy is hcmny iurnishrd. COUNTY OF LOS APJGELES , BUILDING AND SAFETY � ' i � Certified copy is tiled��9th the caunty builling inspaction . . BUI L�ING � dapartmenc. FOR APPUCANT TO FILL IN : /-� " IPqINT Oft TYPE ONLY) ' ADDAESS L'S �_��� Date Applicant ^ /�� LOCALITY le3_���;,��. � CL:I2TITICATL 01�EXLr1PT10V[�fL01115'Q�t{�ERS� NO. TVPE OF APPLIANCE OR EaUIPMENT �'. F[E _ _ ._ C0:�1P£NSATIONINSURANCI NEP F,- } (TftiS SeC�ion need not bC COmp�cfed if thC ��'otk InVOIvCd A650RPTION U�11T,6TU � ' � ' by thc permit is for one h¢ndred dollars (S1D0)or less.l oisrn�eTNo. �� ra'� - V I cer[ify th�t in the p�rfprm�nce o(the warA for�.�liich this AIR HANDLING UNIT,CF�t � �7� I O permi[is issued,I sh�ll nm employ�ny persnn in any manner " � ;� � � so as tn hecnme subject to�he\4otkers'ComD���so[ion La�ti�s, BOILER,6TU � ..�---- MPR�VALS �DATE iNsvccro�ssicvaruae W D�te �— AF4���cant C0�1PRESSOR,6TU ROUGH � • N � NOTICI:TO AVPLIC:INT:IL after msAing this Certifi<a[e of VENTILATION SYST[N, FINAL �_f _� .—r Exemp[irm, ynu shnuld beeome subject tn �he W"orkers' G� Compcnsatinn provisions uf the Labor Code,you must forth� - i I - , �vith com�ly with such provi.i�ms or thic EVAPORATIVE CODLER , permit shall bc � VALIDATIO� deemed fevnkec�. ' FUFiNACE: FAU-GRAVITY_ . ' [.ICI:NSL:DCONTRAC'TORSDL:CI..4RATIOV FLOOa; BTU � 1 here6y affirm[hut 1 am licensed under provisionsof Chapier � HEA7ER: SUSP[NDED UNIT 9 (cammencing with Sec[ian 7000)of Uivision 3 of the 8usi� � WALL � � '� � '�, . . . . � . � ness and Pmfrssions Code,nnd my�icense is in full Foree anJ � �� � � � � � effect. ? / - � /� - , License Num6erc.1.�E1�Lic.Clus�,p"�� � J ' . ���,«���a���/�a�����.,�J����e__.b---1_�—�� r u' - - ' - �� 1 um�a�w-j�C ft�m tht licensing reyvirements as I am a � licenxd ❑rchitect ur a registered pro[essional cnginecr p�an check fee 25°S of�boVe. , � actinr in my professional capacity (Section 7051, Dus- � '- �� � �� ' - �� iness and vrotessions Code). PERMIT ISSUING FEE;S ��Q � �, l.ic.or 12eF.No. ' Date TO7AL FEE , � � -� ' � �, 8�,��A. � FIOSiC Ol4'NICR-BIJILDi7i Dk:CLA1tATION . . � ��.�� � . . .� . . �r e�°''� �i 8 PLAN CHECK APPLICANT , . .I."2�5 O 1 hereby affirm [hat 1 am exemp[ 4um�the ContractoPs . NAtitE . . � I.icense La�v fur Ilie follow�ing reason (Section 7031.5, Husi- I L".�+Q,��5 p 2 ness and Professions Code): AD�RESS � ' � � � � I, as nwner ot tlie property,wiil do Ihe u-ark and thr � -� I . ��C,1 E 8� � structure is not intendeJ or otfer�d tpr salz (Sectiun CITY TEL.NO. � i � 7054,I;usine>s an�Pr��fessinns Code). � OWNER ���� � J � i,as ownrr of t6e propertY'.am esclusivcly contracting _ _UJ"JGC%��.J� . � �sith licensed contractors [n eonstruct Ihe project A1AIL . ' (Section 1044,�usiness und yrofessions Code). ADDF7E/SS � _ i � CONSTItUCT10N LLI�DNG AGI;NCI' CITY/`/ ` � - L.NO J ��f� � I I�ere6y aff�rm that therc� is a cunstructiein I�nSing agenc� «f " � � for the performance of Ihe •wrA for ��hich this permit is CONTFlACTOR �C�M� �L��� -� � - - - �-.� . issued(Sec.3097.Qv.C.). ��- � . .�`- � . � .. . � LendePsName AD�RES5.7�O' �y � �. , � - - � � Lender's Address � /L � , 1 certif} th�t 1 h�ve revd thi��Pt'lica[ion and 5[�te tl�al the CIT����`�' TCL.NQ��iJ i//L)/J _ . . . . .. . .. � q_!"rl! J/ � abovc informelion iz correct.I a�:rce Io colnpl)'wi[h JII CoUn[}' � UCENSE N• � � �p'/9 CL SS,.,/��f�� . ,_. _ . ._ _ .. . .. . ordinonces and 51atc la�+'s re�ula[inF flcat�n�:.Ven[ila[in�;und 9 . . . Air Conditianing,and hrreLl':�uthorii.e represantatires of Ihis SCE RCVlSRSf.FOIt I;XNI.ANATORY I,ANGI�AGF; . ' . C ty to enter up thr ubuve-mentioned pruPerU' for � . � . . . . �--..... . . ._.. 1���,���r<,s<s. � —:/�_>2�'..et�_L��'.,�GC���..,// _ .. _. �ignature f I'�m�ttee . �-te . . _. . . , _ ., , � . _ _. ._... .. . .._ ...... ._ . ....... . .. ... ... . ..'. i . INSPEC70A'S NOTES - � Atiti'NGR•BUILDER DECLARAT►DN 1 • ;. _ , , . � . � � � �' "I�hcreby�affirm t6at-1 am cxcmpt from[hc Contractor's , - Liccnsc Lau fnr the fofloo�ing reason(Section 7031.5," • Businers and Projessions Code�: Any city ar counry�� . � ;-1 �K•hrch requims a pennit fo construcr, clter, improve, � -' � .. - -� . �� . • , � � dentofiah.os repair onv swcrure,prior ta its� istum�ce, � � � - - � . also �equirer the applicuttt for auch pennit ro fi(e a `��`. ' • �- -- - - sigrted slaternen7 fhat Nc ir liceirsed purzrmnf eo the � . , prorisions oj die Conrrarror's Lirense LaH�(Chaprer 9 � .. - .. � . _�- :.y �*� .. . (commenririg witG Section 70001 of Diri.riorr ,7 oj tl�e � .. � � " • �� Bnrinerr m�d Aofersio�is CbdeJ ar diat !ie is exempr � dierefronr and tl+e basis for!he Rlleged exrmp7ion.Any .... . � -. ��iolarion of Scetiun 703(.S bl'onY applicar.t fora Pennil : �. � aubjecrs 71+e apptirm�r m o ciril per�alq�oJnot�tore d+me � � fire lumdred da!lars/SSOOJ.: . , ' � ❑ I.as olcner of Ihc property a'ill do Ihc�cork,and - - � ihc structurc is not intcndcd or ofCcrcd for ulc. _Y--- � ' �- -" . ' `. � ' (Sec. 70dd. Ilusiiierr pnd Profestinr+s Code: T6e Com � � '� traclor's Lrccnae Lax�doef not npplr to mr o�rner of� � proprrty wko buildr or improres rlrcreon,a�+d w�lro does � sudr u•ork lrrmtrelf prorided timt sud� irnprm•emerits � are nor inlei+ded o�nfferrd Jor scle. /f, ltowever, the � Guildii+g or rrnprovement is sold withiir one��ear of � conepletiar, rlre oivnervbur/der �cr(! hm�e the burdeir --�� � � � oj provLtg thar he did�not build or rnrprore for �Ire � � - E-:`. . _ , ' .. Pusposcojsalc.J � _.:• . � . . . _ ' . , '-[j.1, as ti�+'ncr of tl�c properiY.�am crclusively com . - � _ ... . - � tracting�cith liccnsed cunhac�ors to construct thc projcct , �,(Serlioh'JO1J,-�•Busruers and ProJestions Cqde:-Tl+e Com lractor's License Law does nof applr io an,oivr�rr of properfy }rlio buifdr or impra'es thercorr, and ieho . cailmcfs for sucir projects�virh n rontrauor/s/lrre�raed . . - . . . .purrumrt to tlte Coruracfar's License Lax�J.� . . , _ _ ��-.M1 . . I�m exempt under Sec. 6&F.C.for diis reasun -,. Date ! ` , c: ..' `r• Owner \1; . 'c'; . _ - INSPECTOR'S NOTES � � � � � ' - • � � ' � . \`-.. � . . ` . . . . � ,.i . .. � - . ..