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HomeMy WebLinkAbout0529A (4) ,R'OIiK1i1t5'Cq11P1'NSATIOND['CLARATION 7sA3saC 1 herehy affi Jn [hst I ha��e a'certi(icatc of consent [o self CE-fiifl(2801 A�P L IC�T I O fV FO R P E R M IT , � insure,or a certi(icate of\�'orkrrs'Comprnsatinn Insurance,or HEATING-V ENTILATING-AIR GONDITIONING :i eerl:fieJ tnnj;y-�re�f;}��{3/A0.I.a���ma�J� / I/��r 1 ! /F� Pnlicy NiGV4 (bmp�ny__ 'f � • I ❑ CertifieA mpy is harehy furnishrd, � h COUNTY OF LOS ANGELES B L ING AN A ETY � � ��*,7� � �'01�c��`�� � J Ce tifie�cop)•is filed�a�ith the c�uniq F+uiiJing inspection FOR APPLICANT TO FILL IN BUILDING/' � . dr�ir- enf��./ AODRE55 /�1t7�T � � Da[e'r��_l1-Applicam � (PRINT OR TVPC-ONLV) (�;`"��T-�-(——.-- LOCALITY ,/J//Z p�Q�// �� CIiRTIf1G�Tl!Ol'liC1i91PT10N rR0\t ll'OR1CIiRS' NO. TYPE OF APPLIANC[OR EQUIPM17ENT F[E ��-�/�J��! F CO�IPICVS:ITIOV INSUItAtiCG - NE'AREST �. i (This <ection necd not 6e completed iF the work im•ohrd A[7SOf�PT10N UNIT,BTV caoss sr��E� �q/�'j(�.��j�-�J O by tLe permit is for one hundred doilars (S1Q0)or IrssJ OISTRICTNO. PROCESSEOPI' V 1 cerfify thet in Ihe prrfnrmance nf lhe�vurk(nr�vhich this AIR HANDLING UNIT,CFM `O �� � permit is issued,1 shdi not employ sm�prrson in any mannrr . ' �� � co a�to becume subjact tn Ihe��'urkrrs'Comprnsation Laws. ROILER,6TU �- q(� /, /� AF'�'ftOVALS DAT I� TOR'S .GN/+Tt�� (J , ����� `�P�����"t /� COMPFESSOR,ATUo�/ v 0�_���a�V� ROUGH i� � � NO"CICIi TD ANPLIC.\NT:IG a(ter making this Certificatr of VENTILATION SYSTER1 I FINAL �� Z Errmptinn, y�nu should hetnme zubjer[ [o �he \1'nrkers' - Cnmpent�tion provi�inns o(thc Lahnr Code,you must Gxih� ���ith romply aith such proricions or ihis parmit xhall be �V:.^CR:,TIVC CCOLER i � � �au�a�tbi� deemed re+�oked. FURNACE: FAU— tt,V T ! . LIC��SI:OCOtiTRACTORSDl:C7,ARATIOV / FLOOR: a7u l/d�a�/:O� � I hrrehy affirm that 1 am licensed imder pm��ialuns of Chspter NEA7[R: SUSPENOE�'� UNIT . � 9 (commencing�eith Sretion 7000)nf Uivicinn 3 nf the Ousi� LVALL ne�c and Profr.�inn5 Cudr,:nd my liren5e is in full(nrce and effrct. 11/ �/ ) Li�-n�e N/�'•'mh��O��� Lic.Ci�ss��`-' �arac�.`.-"/�� rlN�a[e—!f-✓-� . � 1 am ezemp[ from�he licencin;requiremrnts as I am a Iicensed architect or s regictered profrcci��nsl rnginrrr p�an eheck fee 7.5°6 Of 3bOve. actin� in my profeaaion3l capacity (Seniun 7051. Rus- � inrasand��rnfes�innsCode). PERM11171SSUING FEE S Lic.orRrc.N��. D3te TOTALF[E �_ �'� • HO\SC OR'N}iR-I3UILDLR DLCI,.4RATIOV � pLAN CHECK APPLICANT 1 here6)' affirm th�t 1 am erem��t from'the C�>ntractor's NAh7E I.icense Law for the (ulln�eing reasnn (Section 703L5,pusi- nc�s and I'rn(cs�i�ins C�ic!e): AODR[SS , � I. as n:•:r.:: r,f thc p:npr.,.•.�ill Co 1l�::�a:l:ar.J tlic ��57 Q A x[ruc�urr is not in[ended or offered (or ssle (Section CITY TEL.�JO. 7044,Rusinesc:mdProfcssionsCodc). ,�j/�/ #�'"�• • •8 f,as n�rner ot the m rr[ sm eKNusively contractin OWNER ��j/ � L� • ❑ � P Y'. S O��! ! �l�G��� 9_-'� �I�•488.50 ��'ith licensed caniractors to construct [he projtct A4P.IL ['- (Section 7044,Ducinevs snd Profrssi�ins Code). AODRESS ��J � _��--� •4 8 a 5 O U ,{7 �. CONSTILUCT70'd LENUING AGHVCY CITY ��! TEL.NO. � , 1 hrreFS' af(inn [h�t therr is a cunstructinn IendinG,gency �-rJ 1-1.0 9—8�� (or the erfonnance f Ihe �eor� r a-hich1 his �ermJ t ic CONTRACTOR-�/`ici/7� `�G-.�^'L icsued(Sec.Jn�-,�v. l � ✓/ / � ,y��,/ � � I.endrr'sN�m���r�r ��-�'� GJ Ol O`� A�OftE�^ oV- !!�/!L�-✓V_�LT Lrnder's r\Adresf�V � V�/����r � CITY�j�����/T T[L.ND. . r� I ccrtify that 1 ha��c read Ihis ,.plicat on and statc that thc STAIE •'< < LtC. /' �bovc infnrnution ia enrrecL I erce�n nmply�rith all County LICFNSE NO3�i2�3 _ CLASS(,� . ordinancrs:mA State la��� �;ul�ting {cating,Vtntilating and �Air Com�''nninK.������h rel autho.re l[f'�2FCf11JS1VP5 O(�M1IS sr,r arvt:issF�ro�z rxr�.,�N,aroiav i..a�.cu.�cic Cu�m��� t• r s up n • r e�mrntionrd pn perlv fnr ��,�ne� �. �, ��ses. ���� � Sig � 1'e .i;ee Uate � : � . `.. _. ; ' � � � ' 4 r . ,. q � . . .1 ' in _ . � - Q .i . � , -� . . . V� , . . 0 _'.� � � m _... N , .� , . Z N ,t � � 9 ' , N - ' ' .. 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