HomeMy WebLinkAbout1337A \1'ORRGRS�co��i�r.tis:anounr:ct:�n:�non � cE"-si°s�iz-�m APPLICATION FOR PERMIT �
I hrrebY �ffirm Ihat I hare s certificate o(mnsrn� to scl( i . � �
inrure,or a certificateo}Wnrkers'Compenvtino lncurence,cir " HEATING-VENTILATING-/11R CONDITIONING
a certfied cnpy Ihereof(Sec.3R00,Lah.C.) . '
Pnlicy 4n. Cnmpany � • '
! COUNTY OF LOS ANGELES
I ❑ Crrt�tied c��py is hereby turnishe�. BUI LDINC AND SAFETY
� Cerlified rnpy is filyd with Ih r mnty buiidi�g inspe tion -���rr��
6UILDING
p�/tment. FOR APPLICANTTO FILL IN qODFiESS �
1)ate�f�=a�.l�irlicnnt ' _ _ _ _ IP(iINT OR TVPE ONLY) - .
LOCALITY�,�L ��r
CGR7IFIC:ITL OI"EXES11'TION['R0�714'ORKGRS' NO. TYPE OF APPLIANCE OR EOUIPA7ENT FEE
COSIPLNSA710N INSIIttA!2CI> . N[AREST .. � � Mv� a
(This section nced�not be cOmpletcd if ihe �carA involved � A650RPTION UNIT;BTU CFOSS 57. i-�
b}' [he permit is for onc hundred Jollars (51(10)ur less.) �� � .. I DISTRiCTNO. PFCCESSEDEY . O
1 cerlifY����t in ihe pertnrmance ot Ihe u�ork fnr«hich�his i 111R HANO�ING UNIT,CFM11 ' /� � w `�� O
permit is issued,1 shdi nnl rmpluy sny prrs��n in an�•manncr �j� 1V�
so as m herome subj=ct tn the\Vnrkers'Com{+ensation La���s. BOILER,OTU I I—
�� / � PPPROVALS DATE irvSrECron'SSiGvaTU�e �U
Date Applicant � j ICOMPRESSOR,E3TU_b_�r�0 �� � qpUGH a
NOTICI'TO AI9'LICANT:If,after maAing this Certi(ic�tr of � ��-' �
F.rem tion, VENTILATIONSYSTE�4 FINAL �� ?
p you should becnme suhject to thc 11'nrkers' I
Compens�tion prarisinns nf ihe L�har Cnde,yn�must f��rth• [V:,PORA7IVE COOL[Ft
�eith camply �cith sueh provisinna or this permit shall be I VALIDATION �
dcemed recnkeJ. FURNACE: FAU_�GRAVITY_ �
LICFCNSISDCOVTRACTORSpi[CLARATION Z FLOOR� t3TU_ �p�00�- �C�
1 hereby affirm that I am licenced under prmisionsofChaptcr HEF�TER: SUSPLNOED UNIT
� (commencing�rith Srction 70D0)nf Divisinn 3 of the Busi- WALL - �
ness anJ Professinns Code,and my license is in full(arce and �: �
�rre�c. Z�7 ` �2a C�i'2/ �-- e.�►ti�rt e cS:u—����d C�- �� i
Licenae Number. /�b . Lic.Class.�r _�/ , . �
Conimctor i���� Date�l>�� �
❑ : . . . . . , . � .
1 am exempt from the lirensing reyuiremen�s as 1 am a
licensed .vchitect or a registered profecaional enp.ineer ' Plan check fee 25 0 of above. � .
actin� in my professinnsl cspscity (Section 705I, [1ns- � �
inest�nd PrnFessionx Code). PERMIT ISSUING FEE S s d :=� J�7}�
Lic,or Itee,Nm Datc TOTAL FEE I O� � i!°' •i+ •Cl � -
H0�11i U\5'NLilt-RUILDFR DECLARA7(O*I � ALAN CHECK APPLICANT - Et ' � �i 3.F C
I hereby affirm that I am exempt from�the ContractnPs NAME � ��� ��Cj���x
License I.sw for ihe follo�cing reason (Sec[ion 7031.5, Pusi• . � -
ne�z snA Prnfescinnc Cn�e): AOORE�S . ' 'O 9 '� '��_�,
� 1,as�n��nrr of thz pmprrty,�vill dn Ihe�eorA and Il�r �
s[ructure is no[ intended or offered fnr s�le (Sr�tinn CITY TEL.NO.
7044,Rusiness and Profcssion5 Cude). �
� I,as o�a�ner of the property,am esclusive�y enniracting OWNER �v����S � P���
��-ith licenstd coNractars to canstruct ihe project MAIL �'7
(Src�ion 704d,iivaine�s and i'mfr«innv CnJe). AODRE55�LDrj.�Z ('�L/MA '
CONSTItUCT10N LGNUIYG AGF.NCY CITY��QL�(�a7— TEI.�n'VO. —��a�� .
! herehy affirm [hat ihere ic a cunstrucliun lending agency' �G� /� ��
for the perfnrmance nf ihr ��vrA fur �vhich �his permit is CONTFSACTOR �T±� .
issucd(Sea J097,Civ.C.). ' ' �
Lender's ti�me ADDRESS /�/,�� /`_ /.y� � � - - -
! [ TC.�'��J f✓
LendePs AAdress CITV� / / .1�/� TEL.NO. J� . , �
1 certify�ha� 1 haee read ihis application and s�ate �h�t �he /�
t.t�'•., /7 9�z=�-�y i
❑huec information is cur�ect.t seree In romply�cilh nll Couniy L C NSE NO.��G���7 C AS:�j`�2���'� �
ordinancrs anA State laa�s regulating Hesting,Ventila}ing and - �
Air Com�'tinninK.������herr6y authnrize rrpresrntatives nf[his � SGG itFiVIiRSIi FOIL LXPI,ANATORY LANGUACE
Cuunt fu en[er ipnn lhe •�uee-mrntinned pruperlv fnr �
�. insp�.iinn purpo• >. '
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