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1439A (8)
' �POItKER$'('p!.1pIi.V'S:1TI0.`!hlCCLAR:�TION CEAII76(2�50) AP�PLICATIOf�! FOR PERMIT - � I hrrrh}� xffirm th�[ 1 have u ccrlificale af cnntent fn sclf insure,or n cxrtificstenllt'nrkers'Compensstinn Insu�.�nce,rir � � HEATING-VENTILATING-AIR CONDITIONINCa s certiFied cnpy�hereaf(See.3a0�.I.eb.C.) � , Pnlicy No. Comp•inp , � ❑ C,�rtiei�•d copy is hercb> rurnish�•d. COUNTY OF LOS ANGELES F3UILDING AN�SAFETY � Certificd cnpy is lilyd��-ith thr county builJin¢inspec�iun � BUILDING � n�. dcp�rirr�rnt. FOR APPLICANTTO FILL IN aoor�ess �' 7`�-9 C• �� K. 1)�te Applir:mt ' (PRINT OR TYPE ONLY) LOCALITY D��`KaN� �{Y CtiRTI}lC:1TC OI�I:XE�I1'TIOK FR0�11401tK1:f45' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE (;C1`.!PI'tiS:�TIOti 7\SL`R:1\CI: � NEAREST �iiSe�, Cyp 5'�Yt� �.. (Tliis sectiqn nerd not ce completcil if ilie �eor4; im�oh•ed AOSOf1PTION UNIT.6TU CROSS ST. �e _ V � O by the permit ic frn on^ Lundrrd Jallars (5�06)or Ie¢s.) oisraicrno. vRocesseor U I Cerlify Ih.» in ihe pzrfnrmance nf tl:e,vnrk f��r«liitl�this � �+�Ft HANDLING UNIT,CFA1 � �h � � permit is issued.1 sh�ll nnt rn.�9oy any per<_on in any manner U 0 - so ss tn brcnmr su!,i.•ct tn�6e C:��r4ers'Conp��n�atinn Law�. BOiL[R.�TU h f1�tC .11'ili:z�t I � � 1�+55 � �p PPPROVALS DATE IVSP[CTOn'SSIGNAT`�+E �U COMPRESSOR,6TU _L-- S o, FiOUGH N NOTIC}:TD A4'PI.ICAyi:If,oRrr m�kin:this Crrlificate nf VENTILA?ION SYSTE�d FINAL � �'� KJt.a'✓ln__ z Ifxrmption. ynu shuuld hecnme sc6ject to the 1l'arkrrs' �„"" __ Cnmpen<�tion ptncisinns nf thr l.:ihor Co3e,y�ou I�uS�fnr�h- EVAPOI7ATIVF COOLER ���ith cnmpl}� �vith �uch pmri,ions or thic prrmi! sh:�!I h VALIDATI�N deemeA rrvnkeJ. FURNACE: FAU—_GRAVITV LfCI[.^1SGD COSTI;A('TORS UIiCLARqTI01 FLOOf�: BTU I herefiy�afFirm fh;�t 1�n Iicen�e!1�ind.•r rr��visirins�.�f Ch��ter HEATER: SUSPENO[D UNIT �1 4 3,9�A 9(rnmmencin;with S:niun^.000)nf I)ici�ion 3 of lhc Ilusi� VJAIL , . nrss:+nd Prnfeaians Cnde.and r�y licrnse is in Gill forcr�md #� �.•.• •8 effi•ct. Licensr tiumhrr I.ia(]:�cs '.,• .,��5 O . Contractnr_ _ D.atr , •,• :,��.5�o U � 1 am exemp[ from thr licrnsing reyuirementc as i am a ' ' ' s�r�s�d ,�cn���•« <. :� r�,�«rr��� �r�,r�.s�on�i ��F;�r�•r Plan check fee 2540 of above. 0 2 D 3=8�2 , acting in my pro(rs�inn:il capacitc (Scctiun ^051. Ilus- . . �ness�nd E�rotct.f�m�cndr�. PERMIT ISSUING FEE S �j� Lic��r lice..`.o. P.stc TOTAL FEE rj li0!Sli O`.l'tiF.P.�ilUll.DFit I)P.CL:\RA7'IOh � PLAN CHECK APPLICt1NT 1 hrren} affirm ihnt I am ex±mpt frnm�Ihr Contr,;c:or'.s NAA1E � /� Llcense L.a�c(or Ihe Culln��eng reswn (Scction 7071.5, f�usi- • ness:�n�yrnfrs<innc('r��Ir): - A��fiESS . �_ t. :�c mvner nf Ih_ prn;:rrn�.�����I dn tl�,�cor}:�nd tlie �CI7Y TEL.NO. � rt;u^.tur� 's r��n iulrndrd ur niirrrd fur sale (Srctinn � 704.P,pusinesc sn,i Prnfrsviqns Codaj. /��o j---^ w' ❑ OSNNER �j��'LG"N C/�f'/'7"�" 1.as�ncntr uf[he prul`crtl'.:im cxclusivcly contractinG (cilh licen�ed cnnlr:icturs tn cnnstruct I,ir prnJecl A1AIL Zy7Zg �,_Turd �• . Scr�ion 7044,flnsinru and Prr�(ra�inns Codc. nDDfiESS COS'STIi4C7IDV L)CVDh'G ACf�:NCY CITV � Y TEL.NO. 6 T�4,�„�c �� sqBG �y [ hrreliy �f(irrtl Ih�[ therr is ���r nstruc!iun IenJing��ency CONTf�ACTOfi for ihe {,erfnrmsnre ol thr �curk�tiir uliich [his Denni[ is 'cucd(Sec.J09;.Cic.C.). / - Lendcr'S.'�'�mt ADD(7ESS � LenArr's Addrrss CITY TEL.NO. 1 crrtify that 1 h�ce rcad Ihis :ipl'lir�tiun:mJ st:�tr Ihat ihe STATE LIC. �L+a�'e inf�>rmali�in i.ci�rr<��[.f�^,rre to cr�mply���itli:�II Cr�iinty _L1� CvFNSE NO. CLASS . ordinancr+and SCitr Ixoc rrrulatinc Hratin�,�'rntila�iny�nd � , Air Cunditinnin.,anJ herebp��ulhorire rapresents�i��rs of Ihis 5!{G Rh:V6:RSli POR ERPLAN.4TORY LANGUAGf Cuun�>' tn entrr upnn thr bncr�r�en[inm,.l �,rapen>� fnr in�pcctionpurp�,ars. � I ��v . Signafure uf Per�rc-� D�Ic`'"�/ . _, ,. f .. , • '.1 i .. • ' ' / . . � .. • �% " � � y �� • I f i • . .- . . ;i J . ' . Z N • �o � n� • D � • - N ` � O - N ' q -. �� � .. ' N , O.� N . _. 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