HomeMy WebLinkAbout1313A WORKERS•�oMPENSAr�oNOE«ARAT�oN � . qPPLICATION FOR PERMIT �
I hereby affirm thot I hove a cerlificote ot consent to self
insurN,or a ter7ificale of Worke�s'Compensalion i�s��a��e,. . �bA�� . HEATING - VENTILATING • AIR CONDITIONING
or S cerrifled copy thereoi(Sec.3800,lob.C.) -�_g�g�REv.�oiai) -- � - � -� � � � '
,P❑olicy No. Company COUNTY OF LOS ANGELES - BUILDING AND SAFETY
Certified copy is hereby furnished. �
� Certified copy is liled with the mumy boilding inspeo FOR APPLICANT TO FILL IN eu��o�N� ��i�S' ��v��� t�
fion deparlment. • ADDRESS Vn,
• (PRINT OR TYPE ONLY)
� Dote Applitanl � LOCALITY �I�O�}(, ._{2
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE�OF EXEMPTION fROM WORKERS' NEneEST
• COMPENSATION INSURANCE CROSS ST. C"T�-�'��
(Thl>>eclton need nol be completad if}he wotk Involved by ABSORPTION UNIT,eTU DISiRi�i NO. VROCESSED BV �
the permi}i�for one hundred dollars(SI00)or less.) _
. I cerfify ihat in the performance f ihe rk(or whith Ihis NIR HANDLING VNIT,CFM j O
permit is issued,I shall not emplo y r n in ny manner '
C
— SO�S 1 bECOm Subje[I to fhe Wo 'an Laws. BOILER,BTU APPROVAIS DATE INSPECTOR'S SIGN0.TlIRE —
Date I � pplicant COMPRESSOR,8TU ' ROUGH
NOTIC TO AP LICANT: If, afte �Ihis Ci rtificote-of VENT�L4TIONSYSTEM FINAL
E.emplion, you should-bg �s bjed to i e�Workers'
Compensotion pro��sfons of the Labor Code,yov musl iorth- EVAPORATIVE COOLER VALIDATION
with compiy wilh s�ch provisions or this permit shail be .
deemed re�oked. FURNACE: fAV_GRAVItt - "
� LICENSED CONTRACTORS DECIARATiON FtOOR BTU � -
- I hereby affirm the�I om Ilcensed under provisions of Chopter 9 HEAiER: SUSPENDED UNIT_
.�(commencing wiih Section 7000)of Division 3 of ihe Business ' WA«
apd Professions Code,and my license is in full forte and ef{et1. ' � � �'
� � � / �'�^'f3�11 I Q p
License Number� Lic.Class � � p� ,� . / �� , U
v(�Cv�e/ �
CoMrodor Da1e �� � -- � �
F
❑ I om ezempl unde�Set. ... . . �� 3� j�'� w
Plan check fee y
B.BP.C.for this reason' pERMIT ISSUING FEE S �� �T7 �• • ° • •8 z
Date:
Signc�ure TOTAL FEE I • •2 2 2 5
� OWNER-BUII�ER DECIARATION PLaN CNECK APPUCANT �— �� �Z 2���
I hereby af(irm Ihat I am exempt from the Controctor's license ^� . D .
Law for�he following reoson(Section 7031.5,Business and NAME D 9 0 1 —8 8
Professions Code): � � �
� I, as owner of ihe properly, or my employee5 with AD�RE55
woges as their solc compemalicn,will do the wcrk end ��TY 7EL NO. -
. the structwe is not intended or offered for sole(Setlion
7044,Business and Professions Code).
OWNER i�l.�i�1�'�. c-..`l ��NEL�s,
❑ 1,os owner of Ihe property,om exclusively contracting �cv� f1
wilh licensed conlrac�ors to construd Ihe projed(Sec- DDRESS��+'�7 S. �'(J���}�C� y� , '
tion 7044,Business and P�ofessians Code). '
CONSTRUCTION LENDING AGENCY - - an' p(��(`>- � TEL.NO. - - -
I hereby oifiim Ihar ihere is a consrrocrion lending agency for
1he performante of ihe work for which Ihis permit is issaed CONTRAROR ��'�(U��_ �t]�L���� �" ,
(Set.3047,Civ.C.). � . . ..._ . ..
' � ADDRE55 � . . . . . . . . . . . . ...__ .
lender's Name
� . CITY TEL.NO. _ _ __ ..
Lender's Address � �� � - �� -
STATE � LIC. .
I cerfify thot I have read this applicalion and stale Iha1 Ihe LICENSE NO. L� CLA55 �� . ..
. . . _ .. ....._ ... __. _ .
abov i or 'on is correct.I agree lo comply wilh all Covnty -
ord(n te anc��$tate aws reloling�0 6vilding tonitroUion, _ �
and re d�f� ' epresenlatives of ihis County�o enter � - � � � ��� --�-
upo 7 rione perry(or inspecti n purposes. SEE REVERSE FOR ERPLANATORY LANGUAGE
� �
i/_ _
Si: ur �ApPIimN o Ageni D te .- . . .. . . . . ._.� . . . . . .. ..--.. .'..
. . i � �
1 � 1
I � �
I '
� ' � �
` . . -- i
m i i . .� . ; -
i • , ; ' -
�y�' �. , .. . ---- .:' i , �
O . i - • � , ' �
m , . . _ , ._
` N ' . P. .. ; - ' . �
. j , . . ' , � . '
� � � � . ..
1 � . . -. I' . .
' � . . " "'_ ..
� . . . , ' . . '. ; . . .
' ; ' I ! �� . .. ., '. � ...�' � .. . ._" ". .. . ._ _ . . . .
1 . .
� j I
• _ �
� 1 I ' . . � . ._ ._ . _ I
� . � - �
� � ' i � .
� � , , '_ ' 1 ..
_ r i i .. _ . ' i , _ . .
� - • _ � �' � . , N
. �
; , m
, , i O
; , N
i �,' ; - . , O
• - -�
� , - . " . . � , " . : , ; N
i , _
. � i � � � . . , ' ' - -' . � ... . . .
, � _ �
I I � / ,
� ,
_ .. , � ' p � �. — T�,� o'in - � o � F E o in s a o,o p'^.��Q 3 c o Q.c ^ _ .
o ❑ � m � s-�_r� � _ F3 oT� o �i °.�.� � o ; n .a � c� S
.. . I . -• � . � W � S O N !� _ �b 9 O N n,± O ' �. N 7 �. � C . > N ..
..__ � 7:. ('D . . � 3 rl .a.r- � a'o p � it- � a� in �, o �p �-p -i N �, �y
. ._ .. , , o �. . X , jocoo� ❑ Qa'� c�,� �:a.^_rN� a''� o-� " oSq '�^ N � �.
� m � ti .�a�vf . � � 3 aN s.� o ,,, ��c o.a.00' .. � o 0 0 0
� - .' . . i . � - ° � ' oNN ° Qf �'° � 4� 0 ° ,� p'° o� ' `"-o:o '" '�a° �� �aF = �
� � n N _ � ` � '^O r -' O . . �c t0�� r- .b'C ,v .
`_ ... � � ' �' - c �'f - f � � f � F � 'ti°' ,•.F 5 ' �-':-�b as°.� _� � 3 0 0 3 �Z ' •
� . . � .. . ' . . � . � I �sb aN N � c =o a°� aN o � •.. j��'°'p � m � � o N To �
ooHc� maa d� � �' o, o 'n' xs< '� H ' u �+ �
.. ' � � _ O•_ ..� 7 � < H � �C � ��p p'N-O p �.�p u; r,n O C n O _
, . - ' o. . c� ' � o « � a$ °mF� „', am � 2� = 'c �b3•�'ooaNm � Noo � .
. . . • . � , •^ ' o o'r�o 0 0� o° �c� s o�o av �' � o �"'n� T� 'c o f �, � .
;. � - f� �� N^ o � �o �,� o..�a-m o � o 0 3'�o c v o � 4� x �
:° °
� - - � ' � - ' ;°� �� °� � a� �T o<'^. o !; � yb.. b � n a .. � 3 p .
v � 0 3."' > >-.- 30'. v_ r^
_ ' • . - . : ' `.o o' N o,� o � o F ' o..N o'� 0 3 ,c �� � o � _ � � o � Cl
. � � „n.� n o o m °.° �'v � � n a� �' � `. � p 'O�.S �'.n o o `�- �
N � ° QU � N o F� ° a� o o a ...Q�o o ' o� o N.� � � 3 D
- . . ' - � ' . � p � " c k o <. o 'D�F � ••.�„-O ' �oo3N30000 $ ms '-�
._.. . - �n � �� ., > >-3 �'� o s -.� �:o '^ 3 < H � < � ; " p�.
_. , , � o o s c 0 w b �' ° o �m°- -�o � o �a> > '"�o m � °c o' o Z.
, --. . .. . , - ' � '� nr�� `o�S. '^ ��n , '�o" =.Q Ta� N o o �� ' ? , .
. � c ° ° � ,t a� a� '" ° ° ' F � o..`� �'o o`4'^3 �'o 0
- o,.^. o
-- . � �� qon m • � e' •N�:�': ,o av°-.^. o� f 000Fc,,•,. -
_a
o °� ° ^ ' a�?° ° �.,� °n° a °a�• � H � �-moo �=,-"'� -