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 ' . . . ... .. . . . . . . . .
. ' _2.. , ' ��
. • . . . .'` , ' . , {�
. �
ti. ,
�'`
. . � �. - � ' � , .
, r ` •
' ' , � a.
' . � , . �.t' . ' � . . .
� ' \- .
, `. , ��,` .. . �' , . .
, . ,. ` . . , , �
� .. . . .`. � .
� ' \ , � `'� • �,�� ,� `� ,,� � �. �
. � � , �'` ' . �' ' .• . ,
�
� , , `' . . . '� ' ..
N � ' �
i, . ' .
,. • .
' ;� � ,
, 1- <•.
_ - ' i ` - - N ..
� ' �, ,,�` \, ,. � r .` � t t�'�
_ 1 �� , . �
�� . _ . . . . . N
� �� ' ,J '_' \ _, `� . '. ' �R'1
� . , �t� •�. � . . � . � N
l . -
. ' `,` � , ' . . .`
�� , \
- ',, �`_' �' �1 \. . , ..- 1
. 1_ �l
' \
- ' .
t� �' , •' �' , .
t t �
. �,'; �` �, Q r��. .
�� ' � � �.. , _� . - • .. . :� p"W.c � m� .
� ` l . . •� . y� ,{!�n0 N�C. C� 7 . a.
7 � �
,, r p,^ o� O r.° 3 u�v iD � W � O �y,
. . � O � �. 'm O p 3 O a p O p � '.. ..
1 �' � ' �'� �,o� o o v,7.n� :. a� ° a f ,• 2
\ � . £ .� � co o �o:-� ov.a
� � , � , � � o � ? oaN QNo � c�.a 'T,o � m .o03 �-n
'° � . �.�.- � '�� � �' '=�`�G `inQ'-� O'°0u+.m'p,� 3 0 �0. .
7 � i' N ��
_ . �� o,,',�G p.��t.; Q^O 6.S C N a� O o^.7 �.O "�� ': �. .� �;S p ��
. �- ' S C ,? (� �._ Q 0. • N � N O<K �l9 � C O N t0 .- � .
� S 3 a. '� ^ �
� p ?6,r���t'O.� p,C � O m N ��.u�.4 ' .a�'�o d o t7� N c p.a oJT �Q . .
. W: � o p.ocm 4 _. oa,�,� ...op.� � 3 m'�.x"�'` r� � !� N '^ o� R' �
� ". R°' � ?,o p,n �'' o o �o f m °m on mw ,'^_ o'a-'u. � C1� m � . J/
p o -o m o m N � �?'" 3 w m o 3 n.N o 0 3 � � �� n'9 � °a-r� m-' .O
^p " �2'o r-�, '°.L v�_o o t v'm o m K 'a �,'�,.- N 7 o A.;o �n 3' tr ,fS
'z �n .. m . a , c._io a-o..^ a x !�
^ .� , °-� � � �, � � za.ofl.° � o..am °° �'� oao�, o'y�''=,. `Crt�
, . � , o...;v ' �-.� a.N �o ^ m � � � o,'a m v :a c � � "�r.� ° �.a a ...
s o a o, �a N o- o . _. .� '^ �;
c o s o o Z• �' m ... _ o
'. - N a , ^�m� c;°�e�`N°�; o T ��m��„°a No � 3� � ��c o oN:_.�. � � �°y�;
' 1 � (1 . N ��N � O•if�. ?'O N �U �p .Q �3 .Q.Q1.Oj-�..r�`'aL NS.� V
.. . � O . O .�o � Ls'O �,C N� �' -� .:'c l�,a�Q , C_ O N N�
. . � • �' N r=� o o ��a '�� ��?s� p.N � f J, N �o � a�^'yn � ^ ^. !� Z
.. , � ' . p ' CJ � '. Q�p 'O.fJ O.O �1 O p .S C a N 3 O .N �'l9 O p p .
o ^ �ooK,� N,�' o � omv � �'a.a �'' �:'��,' oo:,w �N� ma� � ? � .
��\ , . .. . .. , ' ^ � ? o� m,°. � o a-f �o ° ° .....^.."'=a� � �m c 3'c oo, .
' . , , \ . . . . ..Ni� Q'N (� �p Q'd �w� ro � '� . �..Q 7 ..Q � .0 n-.� y� �+N � �
O� O
. : . ' � . . . , � d�,O 7'3 v� <�O_S3 O ��Sm �t SO�V�W','OW O�Q� N n �+`N '
� �
' ' . � ?�'� `^ tD�� d'� o-o n.. � a.�°a^""o N s�`u tD � Z'-
` �, ' :�.� �-• '{ � � T�.C' p N O'?. O ��.j N
. � . , . � . _ .. , _ , , �c ?p.ry � � T?; � cmn O- a
. � � . � -, 'o�"o�p-�, � m o �O �,.�
� � . � , , . . ._ . .. C.O �p,> Q n � O-7 ,,,
. . � . ' '( . ?`N� O �, ��
. O n
i .i . O �