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1672A
WORKERs�oMPENSAT�oNOE��AaAT�oN � � �- APPLICATION FOR PERMIT � I hereby aifhm that I have a ceriificate of consent to self � insure,or a certifica�e of Workers'Compensarion Insurance, HEATING - VENTILATING - AIR CONDITIONING ' or a cer�ified copy thereof(Sec.3800,lab.C.) _ ���� � � ' CE-818(REV.10/81) .-. - . . .. . . Q�y Na.PWC 0506��mPa�Y Golden Ea�le Ins. Ceniiied copy is hereby furnished. COUNiY OF LOS ANGELES BUILDING AND SAFETY � Cer�ified copy is fi�ed wiih the coumy 6uilding�nspec- FOR APPLICANT TO FILL IN euumNG tion deparlmenl. � ADDRE55 . . . . � (PRMT OR TYPE ONLYJ Da�e5-29-R4—nppuca�rR�ncho Air�T�_� ���iT�DismOIId B&I' TI'BCt�{ �+25$2 - NO. NPE OF APMIANCE OR E�UIPMENT . FEE . - CERTIFICATE OF EXEMPTION FROM WORKERS' - - CRO55 51.LOTII G Job!/ 876 COMPENSATION INSURANCE (Thls sacflon nosd noT ba complN�d ff}ha worl[Involvad 6y- �+BSDRPTION UNIT,BTU DISiRICI NO. fROCESSED BY ' fhe permif(s for ona hundred dollors(SI00)or lass.) qIR HANDLING UNIT,CFM � - I certify that in the performance of fhe work for whlch ihis � ,� �0.�'(�'� � permil is issued,I sholl not employ any person in any manner gpiLER,BTU - — so as fo became subjecf to the Workeri Compensotion Laws. .. .+ovaovnt5 DA7E MSKCTOR'S SIGN0.TURE . 1 COMPRESSOR,BTU 60.000 ZO.00 ROUGH �Dale 4PPIic6N . NOTICE TO APPLICANT: If, ofter making this Ceriifica�e of VENTILATION SYSTEM FINAL - . -"`�emption, you should become svb�ect to the Workero-. � fompensation provisions of the tabor Code,you�musl forth• EVAPORATIVE COOLER VALIDATION �"wi�h comply wi�h�suck proviaions�or ihis permit ahall be deemedre�oted. 1 FtOORCE. FA�x BTU ����TMUIIi[f— 10.00 � . LICENSED CONTRACTORS DECLARATION� . Q I bereby offirm thot I om licensed under provisions of Chapter 9 SUSPENDED� UNIT_ ' ,'(mmmenciog with$ecNon 7000)of Division 3 of the Bosiness HEATfR: wA�� ond Professions Code,and my license is in full forca and effecL - . � � y 13 Re isters @ 1. Ea 22. p .license Number 3a�5�3 lit.Class C-20 - � - -- . , � V 167,2A a ComratmrRB➢C110 Al2'�,IIIC.DO1e 8-31-89 � � �� � #� i • • .8 � ❑ i am exempt vnder Sec. - I � �5 3 2 5 Q " Plan check'fee � 8.8P.C.for this reasorc - � PERMIT ISSUING FEE S 10.50 � ::5 a 2 5� ? oore: Signorure TOTAL FEE , d Q G Q-�8 OWNER-BUILDER DECLARATION �- Pt.4N CHECK APttiCANT . � .3t aS ' I hereby affirm�hat l am e�empt from fhe CoMractor's license , , � Law for the following reoson(Sedion 7031.5,Business and NAMe � . � . . P^rofessions Code�: - - � � �� - --�'�J i, as owner of Ihe property,-or my employees with ADDRE55 - . - � � � � - - � � - Jwoges as their sole compensaiion,will do the work end UTY� TEL.NO. the strotture is not intended or offered for sale(Settion . 7044,Business and Professions Code). . .. ' - - - � � OWNER ❑ I,as owner of the properly,am exclusively contietling n with licensed conlmctors to consfrucf 1he project(Seo- �� DDRE55 1074 ParLview Drive.N201 . ��- tion 7044,Business and Professions Code).� � � CONSTRUCTION LENDING AGENCY. '�-� -- C�Tv� COV3II8� ��'�� Hl$-9E)7=954 I hereby affirm that there is a constrvdion lending ogency for � the perio�mance of the work for whith this permit i5�SSVBd-- - �ONTRA�TOR �NL•H� AIR� IRC. �� � � ', (Sec.3097,Civ.C.J. � � � --... _ _.. . . ._ . . ._ . - aooeess , 1232 W. 9th Street _ _ _ : ;_• _ lender's Noma an _ _ ..�pland te�.No. 714-981-480 . lender's Address �� � � STATE IIC. I certify that I have reod this oppiicotion ond s�are that the . uCENSE NO. $O �L - CV+55 r.-2� � - �� - -- -� - � - � � -�-- -__ ._ . . obove informalion is cortett.I ogree 10[omply wilh oll Covnfy. ordinances and Stafe laws relaling to building conslruction, � � . and hereby authorize representalives of ihis Coonty to enter '' � �� - - � � � �' � - ��� � �� � -� � - � upan t a ve•menri 8ed property for inspec�ion purposes. ' SEE REVERSE FOR EXPLANATORY LANGUAGE o��Ll�l�o �'a�/-g��" Signoture of Appliconl or Agent ' Da�e . � � . . . � . . � .. . . . .. ...... . .. - .._.-..' ' - .- . . . . . . . . i - " � ` � � '', . ` ,,, `` ,, , ', ; . ' � � ' � � , , ' _ ','; , ,,, _ . . . . . ' . 1 ! ..�. ,`` y: � � . '���' � ` � '.. t �� � -. � . .`, . _ .i•(J •,'. .. . . .. ' , f - � .. . - , ',,.r ��.' , � :{, . ':t _ � � , _., :;. ;.� _ ����, . .� ♦ �.� � �� � . . - � , � t �i � ' , -• .. _ .. � � ', ,t ,.. . ,� ' , Z • � _ 0 � � �� ' � -- � a '� t�i� . \ . 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