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HomeMy WebLinkAbout1266A __.--- -� COMPENSATION DECIARATION -� ' � � . ,(1 I have o cerlificale of conseM to 5e�r I APPLICATION FOR PERMIT j� �_ ..e,...E�•., F'cota of Workers'Compensaron�nsurance, ���3�ac �-HEATING - VENTILATING - AIR CONDITIONING L� o`r a certified w�[y�hereaf(Se�.3600,Lab.C.) LZ�b_t( Cf-81 B(REV.10/81) .. P❑olity No.V ���7-1 Co'paoy STATs�cu 1� . � . Cerlified copy fi hsreby iurn'rshed. COUNTY OF LOS ANGELES BUILDING AND SAFETY � Certi{ied topy Is filed wlth the munty b 'I��; ec- FOR APPLICANT TO FILL IN ewioiNc 1 . fion deparlmem. � / (PRINT OR TYPE ONLY), ADDRESS G�C7 E, �TlocpeN�21� Dafa 9'�'`a7 aPPlicom /"''�" LocAUTY �1���� A2 . CERTIFICATE OF EXE1A ION FR ryvwORKERS' NO. TYFE OF APPuaNCE OR EOUIPME FEE NEAREST COMPENSAi�ON IMSUfiANce CRO555T. jf�/nOA�O 3A/L Ql.V U (Thtt sacllon naed no}6�complat�d if th�work Involved by AgSORPTION UNIT,BTU DtSfRICt NO, pRp[ESSED(^9�Y the permil i�ior on�hundnd doliara(j100)ar lass,j � q�R HANDLING UNIT,CF pHy�7�y���`�'I \ \� I certify fhat in ihe performance of the work for which�his permil is iss�ed,t shall nol employ any person in nny monner �0 �CJ` so os fo become subjecllo the Workers'Compensotion laws. . BOIIER,BTU ' qvvuovnis DR/E INSPEQ 5 5i rvaTueE Date appliconY � COMPfiE550R,BTU G �� ROUGH NO710E TO APPLICANT: If, offer making fhis Certi(itofe of VENTIlAT1pN5V57EM � FINAt '�- Exemplion, you should become subjecf to Ihe Workers' �Compe�sotion provisions of the Lobor Code,yov mos�forih- EVAPORATIVE GOIXER � VALIDATION with comply wilh such provisions or this permit.sholl be � � �' deemed revoked. � � FURNACF, iAU G T � . . . LICENSED CONTRACTOR$DECLARATION � FLOOR BTU � �� I heieby ofiirm that I om litensed under provisions of Chapter 9 � SUSPENDED UNiT - NEATER: '(commencing wilh Settion 7000)of Division 3 of the Bosiness WALL � - (� ; � and Professions Code,ond my hcense is In full force and eifed. � . �. �( � V � . �. License Number�42-6� � lia Closs a � � , . . . . � . V Controdor�bs(�1.�n�A- �A1G Doie�'�'$� . ' � - � � ❑ I am exempl�nder Set. `' . l~J � W Plan check fee a B.BP.C.for�hfs reason� y Da�e: PERMIT ISSUING FEE S �O SO ' �� 2 G b A Z S�qnaiure TOTAL FEE � OWNER-BUILDER DECIARATION . clarv cI+FCK AFvtICAntT 7�� ������� � �• • s . .8 I hereby offirm�hat I am exempt irom the Contracror'S License � �-�� . . � ' I • •J�J,n Q low for ihe following reason(Section 7031.5, 9osine55 ond NAME . �� Professions CodeJ: ��� � . � ,� . o 0 o J,j,�Q� ❑ I, os owner oi fhe property, or my employees with ADDRE55 `�57 CL/rF��� �j�� `�3 . _ � wages as theG sole mmpensoGon,will do the work ond " ��n, � �� TEL.N0.�Cr,�,� . ��.�1 -R�] 1he strudwe is not intended or offered 10�sale(SeUion 2�6� 704E,Businessond Professions Code). . �. � � � OWNER�� GACVA�Y C��{EQr�1� GNAPEL— � � ❑ 1,os owner of 1he properfy,om ezdusively�connacfing MAtL 't wilh licensed coniractors to consfroct fhe projed(Sec- qDDRESS Z33b C5 oL�E� SnQ�N � � � tion T04�,Business ond Proiessions Code). CONSTRUCTIONIEN�INGAGENCY -� - ��n.n���� �� . �� � 7�q.1� .7� , I hereby offirm that ihere is a construction lending agency for " ► , . 1he performance of Ihe wo�k for which lhis permit is issued COMRACTOR C'.�S v�.l.)i �'0��, �NC. � -� �Sea 3097,Civ.C.). . . : . . . n '.. . .. . . ADDRF55 3�7 CLIFFyVCoD Yh(�,� `,g// � _. � . .. _ . _ lendei s Name .... .. .-. . ��-'.. . . Lender's Address -- � . . C�iY�e�� . . .TEL NO. 9��1�q7 Zeit4 _. . . . . ._ STATE �t�n /� LIC. � I certify that I have read this application and s�ale Ihet Ihe UCENSE NO:�-T'I�Z�`t CLA55 � . .. . above informotion i corr t.I agree to tomply wiih all County � � '�" � ' �-� - � ordirronce d S �e s r ta�ing lo building construcfion, � � � and e au�h iz r pr niatives of this County to enter. . . ... .. .. .. .-. . .. - -. - . ... . .. . . . op t obov on pioperry for inspec�ion porposes. SEE REYFRSE FOR EXPLANA70RY[ANGUAGE /... J ' k cj''/-8�, _ �t�re F A li<ant or Agenf . bo�e ' . . . ... .. . . . . . . . . . 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