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0778A (4)
W'Ot2KFK5"COMYgN9ATtON DBCLARATIOiE '� 76A364C q } q �} C/� A � I here6y affirm that I hu�z a ccrtificate of consent io selF " CE-87 g(2-80) P1��6�I�/"'6 T�Q 1 V `V� P���f T insure,or a certificatz ottiYorkers'Compens�tiqn Insurance,oi HEATING-Y/EPITILATING-RiR CONDITlQNI�iG a ce=fified copy thereof f5ec.3&00,l,ab.C.) � Poticy No. CompanY — �. ❑ eertified coqy ss hereby furni:hed. COUNTY OF LOS Al�IGELES BUILD3N�AND SAFETY =---------- �.f.rtified copy is filed wuh the�ounty buftding inspaction .� BUItD.NG �y � '}� .v / 3epartment. FOF�APPIiCANT TO FtLL!N / �coaEss d� 0` .�.tCrr.(✓s,¢.�.�-v Dnte - Appla�ar�t - . (PR)NT OR TYPE ONLY} . -- — -- � - -- . . . . ,�— _ ....._. � _...- LO�ALlTY G�.RTSH�ICATE OP EXET9PTI�?�F120i'[�YORKERS' �NO. �TYPE OF APP�IANCE OR EO.UIPMEfVT FEE � . ____..���.![��"V COM!'1N51TION INSUR.':NCE �""��'-'��--'" NEAREST (This u°clion need nnt be compTeted tf the work involved ABSOPPTION UNIT.BTU I CROSS ST. y . . ..____-! 0 b} the permit is fex onc liundred doilazs (5100) or less.) , � j i � ���sraic-uo. �-Paogr�,s-o av� �ermit�s�4c m'�suhi�t�tr�th�f t5��rkers�t:�mp��a� ;nnl s�v-sj. - BOILEfl.BTI.—� d!�-a-�7- �.''��'". A ��' �A�'E ' •�� ___.� O L cert�fv tna? n the edorma�ce nf the tiNock tae which this A�R HAPilD,LING UNh_T,CFM-__ � 7 o as co}� / S //1 y"� ��," //j� A PR V.�a '�Nsr�Sb�.ss,va?uRe� U Uat�J./-!,/.�Appl�c�r.t,�.�✓-�/�J._ _ _. _.__— � COMPRFSCOR B'�'U.--- .__... .� �_�—,i. � -- -��- �- �---.-� W _ _-___-__. i I .....,.n f ... V1 NO'[�L t.Tt���r7vis un����rov siUns�r�th 5�Permit�icaorth� � � � � � � FINAL ..�.__������� � ! ( txem tion, � VFNTlLATI(`P.SYSTEM _ p you sho.�ld becone suF x-- to the Workers' i Com eneat�o❑ c e I, EVAPORATIVE COOLER ��rth con:�l7 �:ith ,�uch ha�; t-e � j VK���AII�(� deemed revoked. - �` —T�- � FUPNRCE: FAU_GflAViTY,__; . LICENSLIICO�TRACIOIZSDECLARATION FLOOR: BTU_ � 1 heceby affirm that i xm licnnsed under provi;ians of Chaptcr HEATER: SUSFE�CED UN:T 1� 9 (eommen�:ing w°ith Sesiion 7DDC)nf-Division 3 a"Yhe Busi� � � WALL � - I ness and Prefessi��vs C«de and my Lcease is ir f-a���e�^e and � efTecf. - ^ � LicenseNwrb�r��_��j��� �L3cClass_��� � � � �.' �'`._._" 1-��-,� -f� ' � Cauruclo � Daee- � � ; i -� � I am exempt from the licattsing requireinents as i ain a 1.._____-_ �1 __ ! .-_� licensed erch3tect or a registered profeas3onal engineer p�aii check fee 25°io of above. ` I acting [n my proFess9ona�capacity (S�c£ion 7051, Bus- . '. - ,,.;��� iness and Professinn�Code. P£RMiT ISSUlNG��E�''', Vt � � -: Lic.or Re4.No.____.___..__.____�_llate__-__..__._-_ '({}"�/��,�E� �� HpML Q4VNER-BliILUER DECI.ARATI6N PLAN CHECK APPLICANT � - - - -� I hereby afflrm thxt 1 am exempt ¢nm-Yhe Coatractor's �;qnrE r Licente Law Far the fo7lok^_ng reaso❑ (Section 703[.5, Busi- --- -- � � --� ?� nessanl}���fessionsCode}: . �ADDRE55 �p�( �._ �- - � [, as owner of Ihe pruperty,wili do t6e wUrk a��d tt�e � � ���,�.� svucture is no¢ �ntended or offered for sale (Section CiTY � �� TEL.NO. � . _ __ —_ _ . .- _ 7 , _�ne�nu i__Pe,uor.�Co�e. � . d -�..,�� . Q � . b4ti'NE� /�, � � ' I,a�oµner nf the property,am excIusi�-e!p cuntractin� �_«��'�"`�'X"^'''"� ____._._.. .-� �.�'�7,�A with hcensed contrec ors fo eonstruct the project �MAIL � // . (SectiOn 7044,BusEness'und Yrufessions Codc). ADDRESS __._________. #.a s e •[(,'� CONSZRUCT20.'��LI"sNDING AGENCY � CITY F�L NO. I herct�v a+'f¢m that there is a construction lending agency � -+�'-�' � ��d a 3 3.5 Q � for the perform;�nce uf{he work fOI WhiClt thiS pefmiL,is C�NTRACTOP ✓lh issued(Se: 3097.Civ.C.). ��-!_ . ....__.__ . __-._. -._� o.A °�J�('�}U L2nder's Name ._ � � A�DRESS Lender's Address . _ _. . . ..__.._. . . ._ 1 �,2 Ll"�� CITY _.NO._..._._..._._.._..�_._� � 1 certi£y thaf i have read tiris applicatinn aod StaCe Niat the SrqTE LIC. � above information is correct.1 agree[q comply w-ith all Couttcy LI ENSC NO. Cl.ASS ordin�mccs und $ta6c Inwrs r:gulsiting Heaiing,Vcntilat�ng snd j Air Cenditinning,xnd liere6�3u[hoeize i�efn�esen€nlives af this Sl?P'.3tF:ViSRSE FOR P'.XPLA?IATORY L_`aN:.LIAGt� i County [o cnter upn;t t� ,+hove-me�itionc� propert�= for { II1S� �`,11'�l 1 ...Y. � �/ a���� ��� ; 5, ��`�._ _ _ �,.��- — ,�, ,��. ,,:�;_ �� , �,O q .. , O °' r.:. � N � p ��, � :�U '`�' � . .., . lry,:' Ve- '�.r ,J � 9 p '+t" Tn G , � � -.>..`^." 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