HomeMy WebLinkAbout1672A (10) 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��"
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