HomeMy WebLinkAbout1157A WORKERS'COMPENSATIONDECLARATION . APP�,'CATION FOR PERMIT �
I hereby affkm�hot 1 have a cerlificote of consent to self � �
insore,ar a certifim�e of Wo�kers'Campensa�ion Insurante, '- ' -� HEATING-- VENTILATING - AIR CONDITIONING
or a terlified copy thereof(Set.3H00,Lab.C.) 76A364C � �
� 2E-BiB�REV.10/81) � -- � - - L �
PODIi[y No. 1(191 Sl F Company Rt�1-r Fnnd � �Ufr`�J
Certified mpy is hereby furnished. TR$ 44II24 COUNTY OF LO$ANGELES JOB$ 1111 BUILDING AND SAFETY pH�9 4
� ,Cert�ed copy is filed with the counry 6uilding inspet- FOR APPLICANT TO PILL IN � BU�t�iNG
lion deparfinenf. (PRiN7 pR TYPE ONLY) 1+DDRESS d
Da1e �—�3—$7 APPlitonf - IOCAtITY
NO. TYPE OF APFLIANCE OR EQUIPMENT � FEE
CERiIFICATE OF EXEMPTION F M WORKERS' �-�� NEAREST �
COMPENSATION INSURANCE CRO55 5T. �
(Thls sactlon need no}ho compl�lad 1t fha work fnvolvod by ABSORPTION UNIT,BTU p151FICi NO. FRp�E55ED BY
fha permlf ls for ona hundrad doliors(5100)or less.) � � �
I terlify Ihal,in the perfo�monce'of�he work for which lhis AIR HAN�LING UNIT,CFM �
permil iz issued,I sholl not employ ony person in a�y manner gp��ER,BTU
so os to berome subject to the Workers'Compenso�ion Laws. nopzOvnlS DAiE INSP[CTOR'S SIGNATl1RE
Date �1PPlicant � COMPRESSOR,BTU ROVGH l��
NOTICE TO APPLICANT: N, o/ter moking Ihis Certifim�e�of VENTILAT�ON SYSTEM FINAL
Exempfion, you should become.subject to the Workers'
Compensofion provisions of Ihe Lahor Code,you must for�h• EVAPORATIVE COO(ER VALIDATION
wifh comply wilh such provisians ar fhis permit shall be
deemed revoked. - � - FURNACE: FAU�GRAVITY
� � LICENSED CONTRACTORS DECLARATION F��R .
I hereby affirm 1ho1 I am licensed under provisivns of Chopter 9 HE/TER: SUSPENDED UNIT.__ •
. �(commencing with Seclion 7000�of Oivision 3 of the Business ' '�'�A« . �
and Professions Code,ond my license is in full force and effect.' - � a
License Number Lia Class O � - - - , O
468669 e z9- �
a
Contracror T vin �V Date � 7-23-Si7 . . . . . -. � O
�
❑ I am exempt under Sec. . _ _ . ������7 A w
Plan check fee ?; • • •� a
B.SP.C.for this reoson� � � •�• �
PERMIT ISSUING fEE S I • �4&0 0 �
Dote:
Signature TOTAL FEE �,�Ll A(1 Q�
� OWNER-BUILDER DECLARATION � RAN CHECK APPIiCANT . � � �
I hereby o((irm ihat I am exempt from the CoNracfor's License � � ��G.'"7—�7
Law for the(ollowing reoson(Sedion 7031.5, Business and NAME -
� Professions Code): � �
❑ I, os owner of�he property, or my emptoyees wifh ADDRESS ,
wages as their sole compensatian,will do 1he work arid - � Cltt TEL NO.
�he strudure is nof intended or offered for sale(Section - �
70d4,Business and Professions Gode). � � � � . � - - .
OWNER
❑ I,as owner of the propeny,am exclusively conirocting �i�
wi�h licensed mniractors io construct the project(Seo- qDORESS �
tion 7044,Business ond Professions Code). �
� CONSTRUCTION LENDING AGENCY �- �
1 hereby of(irm thar there is a construction lending ogency Por ��ry Net OYt Beach 92660��'NQ714) 833-3600,
ihe performonce of Ihe work for which this permit is issoed CONiRACTOR � ' �� -
(Sec.3097,Civ.C.). • • _. ._.. .._. . . .... ' -
� AD�RE55 - -• - - � � - � -.. �.
lender's Name
- . CITY_ . TEL..NO. ._ .. . . � . _.
Lender's Address SiaTE ~ � uC.
I certify thot I hove read this application and sfote iha�the � LiCENSF NO. C1n55� c-20 �
a6ave informalion is correct.I agree to comply wilh all Coonfy
- -..._ _ . . -- -
ordinonces and$tole lows�eloling�o building conslrudion, . . , . � �
and here6y outhorize represenlatives of Ihis Coun�y 7o enrer� -_ -
upon ihe obove-mentio.ned properry for inspetlion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
..Jn--� �_��_o� - .
rure of APPIicaN or Agent 'T Date . . . . -. - - - � .. .. . - . . .
_.. �._...._ __ ._.;...� •- - --`
, • . � �
. ,--.. � �I , � i
. � �
y . i t_ : , .' ';, -
_ ,��L � =- ? ', i:
� ' ' '�; � :, , � - 4
� . _ .i� - I
70 �' �-' 'l' ' � . - ` ,.
� ; - ..
� . , - � •
N � � . S „ �
' � ,
, � .. .
' � ' .4. . ' . .
_
. . ."' . ..... . . ... . ' . •` ^ : :
, "� .
� 1. �
1
, ;` ' 1 N
� ; � � �
t . . i , . O
. •, �
; , ' ; '. a
� � � • O
'� � . _ ' M
. N
�. . �' � . _ � . . �i
� ; _
� ; � "
�
' �- � . . ' � .-; . .
.. , . ; �� .... .... _. _.. . . . . � ' 1
, � . . . . . _ � .
. • � � ,' � % : '
�i .' . �. ,. 1 . ' .
� ' . - • .' , � ' �' � 7 a O O p O ���C �.D m � � - .
, � ' N � 3 O 3 � � _,�_�tE � �� �,.N.� � 7. W W �'� N m .
' .. _ � ' � ` S C ]..�,(Np n � ��O fJ O N !� � �. U1 S. �� � N O � M CJ � .
• � . . O ' � ^ O u,.^ . p-q � � r V� ❑a p �j.(1 7 n 7S=,_�n r
' � ' �. , ' Q " ❑ I� � ' f1 T a,� V 7 C 1 � Q S C n A�' �N Q� Q.V O.� N 1 O O O fl. O .
O'O ' � ❑ • t7•N ' 0' Q y O-.-5.0 G y � !L -« C
' .. � n . n . X , ?o:��Af.= o`m ° � n�.� mm ° o�� �.o�.m-'oa„�� � �03 Z .
• m � �,� oc>>"H ' �° o --or-N -•� - c` m o ^N��3.o m
. - , ° v • u «° oN �o g N�v �.� ' ' � 1's' �"•Yo' o ?,� � � �o � ..
�o f � a Q � �a v n � o N � ' �
- � , � , � ��v n_� � m c —° �-��° °'" � o o 'n � o N r-o o� o.o' — C .
� m 0. � o � N a �e °no'o-o H.�'� 't 3 3.�.0 ° °"� ? N u �3 fl
, � . • �j � � C�� N.o o c � a� � a> >r �' � �v c -.no � •
.. � 0 . Q 7 t� O tD � p N O .�C1"(9 -�..p ' %.lJ^-�i �i C O f m
� u, .. U7 . m O '^ 3 0.O S ?O S ('u ,D O:A, fl T �n.= x 70
� � � Q S O � 6 O S� O �- "7 > > p T C TI � ' y 1� � Q
Q .
`,` .. � n £^ mv.�o o � c� `c m�H p o ��,��='o���3 0 0 � o� � .
' - ' � ' . O O ro d� S S� O�'.< p. `G ?, , p.' �`[ N
• . • . ^� �N � � rom� o ?.oNo 3 o W�,c $ � ,, 00 �
• o'o o,� 0 5 0 � 3 0 ,� £ � � <_. ,� c �-._,M 3. � �
' `�° N m °.° oro ° � A°'= �-c ° � ^ � . w�•� —�,i
m �'pp33 °,o �� o 'ao.n°°' � e.��3 � �o,N � � �� m Q -
- " , N ?� a-_ a < ^ ^' f � U ,Z
" ' . . � O � N C % O . O T 3 S� �1� S ,K �n 3�� O 4 �t0 G � C O O
' . . � a„ �'�,= `= �p��3 " �° ��ce p o •.�o a'�h � � � m 3 � 3
�. c y -^ o �
� � -- ,. � � � � . � , I. ..b �°.a ���'o c � Nv f1 � ��9��.�� o do o ��Wo .
• ' 17 fl l9 p q� O �: 'F � O n Q'O p �S�O
, � � . . ' C N � � 9.� S 7 = t�j. 'O � =0 4� ... Q ��S ry Q T�_V`in
_. . . .. - . - . j � � O��+ ' o f� 7 ^ i O 7 4_7 V, `.� 7�`
� � .. _ _.. . '. m O �D � Q'�'O O �...� ^, a ���r-^�
,. � ,. . . . . . • . O O,� n [1 �D �r��-�-�_
.._�+r-r'r'� ��