HomeMy WebLinkAbout1339A R'ORKLRS'COSiPLNSATIOti DFCLARATION �EA e,$`,2.eo,� A p P L IC AT I O N FO R P E R M IT �7
1 hereby a(firm that I ha.�e a certificate o(conscm to self � "- r��
insure.uracertilica[enlR'orkerc'Comprnsationlnsuranca,oi HEATING-VENTILATING•AIR CONDITIONING U
a certifieJ cnpy Iherenf(Sec.3R00,Lab.CJ
Pnlicy No. Cnmpany .
COUNTY OF LOS ANGELES E3UILD�NG AND SAFETY
� �❑ Certified copy is herehy Nrnished, �
� Certified copy is filed with the ouunty buiiding insPre[iun
FOR APPLICANTTO FILL IN aui�oiNc n''
department. . . A�DRESS 1�_, ���1'�J � �
Datr Applican[ (PRINT OR TVPE ONLY)
LOCALITV �A
CGRTIFICA7E OF FXE�IPTION F(LOSf R'ORKL:RS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE �-�- ___
CO"dYENSr\TION INSURANCE CFtOSS ST. s�f��7�-y;)��� d
(This section necd not be completeA if the work involved ABSORPTION UNIT,6TU• - ' �Y O
by tlie permi[ is for one hundred dollars (SI00) or'less.) � oisr�icT No. :necesseo�v V
1 Certify th�t in the perf�rmxnce nf Ihe�t'��rk(��r�vhiCh this �+�R HANDLING UNIT,CFM 'O � �
permit is issued.1 shall nn[empiny a y percon M any manner O
so as tn become bjeM In Ihe�' r' Compens�tion La�t•s. �., _e�,oTU—�� �� f0�p . F-
APPROVALS OATE iNSOECTOR'SSIGNATVnE U
.Uate_'����ApplicanS—--` — � COMPRESSOR.BTU ROUGH � �{7/� _ _ N
NOTICF,TO AI'PLIC.4ICT:If,atter making[h Certificate of VENTILATION SYSTEh9 � � z
Fixemption, you-should become subjcct to the R'orkers' - FINAL _-
Comprnsstinn prm�isinns of ih±LsUor Cude,you must furth- EVAPOFtATIVE COOLEfi VA IDATION � �
�vith comply �vith such procisions ar ihis permit shall be - _
deemeJ rev�keJ. FURNACE: FAV—GGiAVITY_
LICI:NSLDCONTRACTOIISDECLARATION FLOOR� BTU - '
I here6y�affirm th�[I am licenzed unde�prorisions of Chapter HEATER: SUSPENDED. UNIT . .
9 (cnmmencing with Section 7000)af bivisian 3 of the IIusi- WALL � � -
ness and Professions Code,and my licznse is in full force and -
zffect. 1
License Numhtt_�_�_b_�7"�"�,;,.Class
Contr�c[or���t)ate_��_�✓ � �
� I�m exempt from the licensing requirements as I am a -
IicenseJ architect or a registered professionai,engineer Plan check fee 25°0 of above. -
ac[ing in my profession�l capacity (Sec[inn 7051. Bus- �'� 3�9 A.
iness and Itrofessions Code). PERMIT ISSUING FEE S �p SQ
{ . �.�. •�• •a
J Lic.or Iteg.No. Date TOTAL FEE �� !Q
' � ilp]1Ii p\5'NP.R-13UILDER➢P:CT.AR.ATION p�qN CHECK APPLICANT � � �2 a`5�
I htreby affirm Ihat I am eeempt from'the Contractnr's NAM19E �`a�-��t/ -... '�.� �2 a`5��
l.icense Law for the fnllowing reason (Sectinn 7031.5, I�usi• �-—�— s—L•��'v �2 O� `8 4
ness and Prnftssinns Codz): ADORESS
� l, sz o�rncr of[he prnprrty,�+'���do Ihe n�urk and the -
structure is nnt intended or o((ercd for sale (Sectinn CITY
7044,Ousiness�nd Protessions Cadc). .
OWNER �t�
� 1,as owner uf the proDerty,am ezclusively cuntracting . �'�V_ �
�ilh IicenseJ con[iactors t<i Cons[ruci �'�e rr�ject ��AIL `��� '^ ,,.,r�����"� .
(Sec[ion 70a4,�usinrss�nA I'rotessians Code. A�DRESS �f`(j� �l
CONSTIiUCTION LENDING AGVhCY CITY TEL.NO.
1�1'�-����2��a
1 hereby af(irm ihat there is n cansMuction lending sSency CONTRACTOR
for the performance nf the work far �chich [his permit is �`��Q� - , -
issued(Sec.3097.Civ.C.). , !JI••�
Lrnder's V�me AOORE55�1��1 �ti 1 O .
p�ll V
Lender'sA�ldtts5 . CITY �1�`1n ^,�✓' TEL.NO. ��F"5���
I certif [h�t I hace rcad tl�is a Iication and st�te tha[ the ��� �-V �- µ'�
Y PP STATE LIC. \
ahove infnrmatinn is correct.1 aFree to cotnply��'ith all Coun[y L�CFNSE NO.�,�t� �`��LA55 �
urdin�ncts and State��tr�s re latine Heating,Ven[ilating�nd
Air CunJitioning,an.li reby ::r.�otite representativcs nf lhis SEG I2LVERSIS[�OR EXPLANATOItY LANGUAGh: . . .
C .�uy to nter pnn the a+ ve-mentioned property for .
.iSFCCfI(1 F i �St`5. , .
tiiqna[urc Ne�:...l�ee Date ' �
i_` .
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