Loading...
HomeMy WebLinkAbout1426A �ti'ORKLRS'CO?1PENS.ATIONUECLARATION CEA818C12�801 APi'LICATIOM1I�'FOR PER1�111T� � � �1 here6y af(irm that 1 hseC a'crrtifica[e of consent to self � . . � , inwre,ur a certifitate nf 1Vorkers'Compensation fnsurance,oi � HEATING-VENTILATINC-AIR C�NDITIONING a certified cnpy therenf(Src.3800,Lab.C.) I'nlity No. Campan)' . I ❑ Certitied c�py is hereby tumishrd. COUNTY OF LOS ANGELES QUILDING AND SAFE7Y � Crrtified cnpy is Ciled u•ith the munty building inspec[ion department. FOR APPLICANT TO F�LL IN ADIDRESS . ���(,��� ��y Ilate Applicun[ � � (PRINT OR TVPE ONLVI � - � LOCALITV ` \ � CIiRTII'ICATL OF EXE\1FtTION PRO�7\5'ORKERS' NO, TVPE OF APPLIANCE OR EQUIPMENT FEE �_i \`� CO�IPLNSATION.INSURA1r'CG � NEAREST �� . � } {'T�11S 52CfiOn nCcd not he CO111P�C[ed i(tflC «rork InY01VC[j A850RPTION UNIT,6TU CROSS ST. - p_ by tlie permit is for one hundred dotlars (5100)or IessJ oisTaicT n�a � - '�P,�cesse❑ v � I cenify ths[in the performance nf lhe�vork fnr�ehich-Ihic AIR HANDLING UNIT,CFM . _�� �,�,�� v . permit is issued,1 shall nnt employ any pers�n'n any manncr � � �� O _ - so�5[�hrc��me subjeCt to lh,e 1f�'f rkers'Comptnt ir�Ca�vs. BOILEti,HTU \�� � F � �L` /� n - AF'PROVALS DATE ' IrvSPEciOn'SS�GNA7VRE (j t�/ ��,yJv W �D��a_-��y_Applican�/�(��G.._�}-_ ��,� I,� COM1IPRESSOR,BTU I ROUGH � NOTiC(:TO�VPLICANT:If,rter makU[his Certificd� of 1' VENTILATION SVSTEM- I FlrlAl z it<rmption, y�u sli�iild bec�me <uhj t tn Ihe 15'orkers' - Compens�tian pravisinns ut tho Lsbor Cade,you muct fnrth- e�noCRl1TI`.,'E LOOLEP. :��ith ro.^.,p!� •.ci;h such prnvi;ions ur this permit shsil be � Vf1LIDATION deemeJ revnked. � . FURNACE: FAU_GRAVITV . LICENSF:D CONTRACT�J125 DFiCLARA7'[ON FLOOR� BTU � i herehy affirm that 1:im licensed under prn��isi�ns ntCh�pter HEATER: SUSPENDED UNIT 9 (c�mmencing with Sectinn 7000)af 1)i��ision 3 of th��f3iisi� WALL nrss anJ Prnfescinns Code,and my litense ix in fuil force and effect. `_ �y Licrnse Number Lic Class Contractor D�te I r � � � [am exempt from the Iicensing requirements as[am a - � - - - I� licensed arthitect or a tegis[ered prnfessional enginrrr`_ PIe�Ch2Ck fCC 25`,'-0 of above. � scting in my pmfrssionsl capncity (Sectinn 7051. IIus- � iness and Professions Code). PERMIT ISSUING FEE S �� � � Lic.or Iteg.No, pate ' TOTP�L FEE ��� � . HO\1G OR'VI�:R-13UILDFR DLCI.ARATION PLAN CHECK APPI CANT /� �/� / / � gt [i26A 1 hereby affirm [hat I am exempt from-the Contracmr's NAME/ �,(/ [ � License .,aw for[he foliow�inF reacon (Sectinn '7031.i, Busi- (��- �—f/ ���-/� - f . #`�• •,• • •$ nrss-.�1'r�ife<cinnc C�de): AODRESS _0�~i/ �� _�Ellr✓_�'P� � . � I, as nwnrr of[he property,�vill dn thc�votk and the � • �2 Q 5 Q structure is nnt intended or o(kred f�r ssle (Sectian C�TY r fEL.NO�/y�6�� /� •.�!�2 Q 5�� 7016,[3usiness and Nrofessions Code), - (p1 � 06YNE� .T � frJ �� ' ' •' �,� l,as n�rner of the prnperty,am exclusively co�tracting �'�C /L/1� f � �'L a'�-8 4 �vi�h IicenseJ contractors to construc( the project h7AIL ��� � �\ �� (Scctian 7044,pusiness and Professinnc�'ode). ' ADDRESS /�Ly�_�. �� �1 � CONSTRUCTIONL}:NUINGAGLNCY � CITY TEL.NO. , - � I hereby af(inn �hat ibere is a construc[ion Irnding sgency � � (or [he performsnce nf the��vork fm ichich this �+zrmit i5 � CONTFiACTOR ��/ � . i , 'sued(Sec.3097,Civ.C.). � �—� Lznder's Nsme � ADDRESS � � - . Lcnder's Addrcss �� � . CITY 7EL.NO. � l certify[hat f havc rrad this:,��u��uoo and stat�tha[ihe STATE LIC. above information is cnrrrcl.1 a�ree to comply n�i[h all County UCENSE NO, CLASS. ' �rdinsncrs sn� Sfate I�«�s reguia[inR I�t�ting,VentilatinKti��d � � Air Conditionine,und hereby authorize representalives of this SGG RfVICI2Sli FOR IiXP1,ANATORI'LANGUAGIi � County tu enter upnn the � oee-mentinned prnper�y for � � - lG��i ,on purpn�vc, � . �n`�,T -�07"�- J" . -/ Si�nature nf I'yf�tre Jate , / � � : � � . Z • •_ , : � ' � -- - tTt , . . _ �� O _ ?1 - . • • N 2 O . N � ! " y� .!`` • � � O 7? . 1 ,� 2 , • r . N • •�. _ . f, `'L �� ' � �" . '� � /" I 1 , , 1 ` � �r.� ��. \ • . p �r f�: ' . ' _ �_ l��^' � � �. ' � S� C..- � � .v (. ; O H ,�� � r.� ! f. C'� C u f ��'�"f..�C��' No �''�^��� `,,., � � c^� ^�. ^.r � _�•, �s,.��� a � � _ �'�y^ � G �'C ••�� ��� �.� � v �`L�'G:. f �'�', r ....�_' - .. �-�.rr�'� � � � �y � f t� �V ~ � � f C Y ?_ C K L�1... :� ^ C_ ^ _ f.. " . �, �" -� ' " �c n", �'��= o r - .`���,'� c ,�._ r�' � �„r�r_ c. _ ��: `^,..� C�'G . �, � cc � .- � C ��' !% � ,�. �= y,� • _.i r � . - G,�^ - c' tc,u V' � �• � ' v� � � �✓ Cr''- �' ~ - c'r - i, s:."' _ :�Ni,� o , ".i.,^,t' �y^ r;' i. C% r, 7, �� -c h .: �. =�'i � „ � � � ,�,c•, - G ^ ~ '-tl" t ' . Q � � r � G-i� „fr �-' � �� �' �~ C �� ;'.� - t• r 'f •n � f C v-•^`{.� '�fi l' _ �` 4 r {' �O' .-v - f�`G r r- �T.V7f y... v G ��", ' •� !� ' I. � L r� f', � " �. -� R r�-. f^r _. .7 � I' , � �'r: v. - J� �� �� `( _` _ �C, n. C1 r � ' r. i � C...�. -T: y f�v. •~i. `t� f: . � � ,. — �I'� . C:� � ~;: _ �. � �. �a'-r c. C �" .�C G � .. � � _ �C^':.. _ _ - T�. � � ���� ^ _� ' `i.~ �, ='^ .'` �, � ` ..... r,:r. c� _' :. - ' ' h^ p � e� O f: G C' - " c'' C, .. G G.`i i - � ' �.J G . . ` G' ' fI (r - ~^ 'G i i?' =� 'r ..a Cy r-�.4ry ... � " —:. � ,-"" r r. ��. �l�.� �^ c _ .." ::.. �. v�� . '`' �c= _ . �.�� � « �c � c ..�� � c _J '�. _ -_�. � : ' . f . ' � - � ..(^ `� �� r"( C � ' r� y i^ -' ,C� A � r� �� � r C ,� . � �.l�!+ � �C,C1� f% �+ � , ' G`_ �a'�,r C �.,_ f _ '" ^�- - � . C i, r. � - C - �, • , . G G / r ''. i�,