HomeMy WebLinkAbout1293A (6) IVORKGRS'COA7PFNSATION DLCL:IRATION �BA364C A PP L IC AT 1 O N FO R P E R i�ll IT
I hereby affirm [hat I hare a cerliGcate of consent to self CE-81812801 , /7
insure,ar a certircate o(5l'orkers'C�mpensation fnsurence,oi �j j
acertifiedcnpythereof(Sec.7900,Lah.C.) HEATING-VENTILATING•AIR CONDITIONING U
v��i�y N�. 306-82 cortiPany State Cot*ip. Ins. run d
I ❑ Ccrti(iee copy is herehy furnishrd. COUNTY OF LOS ANG[LES BUILDING AND SAFETY
Tract 32576 Lot 24
� �C{erNGed covY�s filad with the caunty building'inspection F�ft qppLICANT TO FI LL IN eui��INc
Dste"e�lr�� ApPlicant Summit Sheet Metal Co (pRINT OR TYPE ONLY) E+DDRE55 1853 Peaceful Hills Road
LOCAIITY
CI�:RTIFICATL OF HKl?1PTION FR011140RKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
N[AAEST
COS�IPrNSATION INSURANCL�.,. � CROSS ST. C}.
(Th15 SeClion nCed not be CtiniplCted if�he tvOrk involved A�SORPTION UNIT,OTU �
by the pertnit is for one hondred Jollars (5100) or �ess.) � . U
OISTHICT N0. FiiOCESSEO BV
I cer�ify ihat irt the per(nrmance nf the work fnr which this AIR HANOL�NG UNIT,CFM � - �
_ permit is issued,I sh3ll no[emF��S"-"Y:'r=on In^ny m+nn?r � —
so as to become 5ubjec�to Ilie SVorAers'Campe^satlon La�rs. eO1LEFi,BTU
� . . . j PPPROVALS DATE MS�E.fOii'SSIGNATURE W
Date AOP��C3n1 COMPRESSOR,ATU I ROUGH �µ_J � _� y
NOTICE TO AFYLIC:INT:ff,after making this Certificate of 1 VENTILATION SYSTEM � O QO FINAL /� �((,/ � Q-- z
Exemption, you should becnme suhject to the 14nrkers' �
Cnmpensa�ion provisions of the Labor C:ode,you must fnrih- �
�vilh compl}' tvith SUch provi51on5 or thl5 pe�mit Shall he EVAPORATiVECOOLER VALIUAI'�ON.
deemed rer�oked. FUPNACE: FAU—GRAVITV
LICENSFDCONTRACTOIiSDECL:IRATION FLOOR: BTU � �
t hereM1y affirm that t am licensed under procisions of Chspter HEATER: SUSPENOED UNI7
9�(mmmencing a�ith Srction 7000)ot Vivision J of the�u5�- W�1LL �
ness and Pmfessinns Code,and my license Is in full force and
effect. � � � �
i ense Number L9$932 Lic.Class C-43
�rsctnr Su(rmit S/P1 pate $�16�83 '
I am exempt from the licensing requirements as 1 am s
licensed architect or s registered protessional engineer p�an check fee 25°'0 of 8bove.
�etin�in my professionsl especit}� (Seetion 7051, Uus•
inexs�nJ F'roeessions Code). PERMIT ISSUING FEE S 10 50 �'1 2 9,3 4
Lic.orlteg.No. Date TOTALFEE 16 50 #�• •`�'• •8
IfO�fE O\VNF;R•BUILDCR DECLARATIOY PLAN CHECK APPLICANT - � � •���� (x�J O
I hereby affirm that 1 am exempt from-thr Contractor's NAME Sus�ait Sheet Me_tal Co.. INC.
License Law fo[the tollowing reason (Section 703I.5, [lusi• •'�"� � h��"
nessanJl4ofessionsCode): ADDRESS 2I811 Belshire St. �
� I, as ow•ner of the proper�y,«�ilt do Ihe u•ork and the —B Z� ,
siructure is not intended or o(fered for sale (Sectiun CITY Ha�aaiian Gardens TEL.N0.52]-8863 0�!1 9�
7oa4,I7usiness snd Professions Code).
❑ OWNER pf. J. Brock � Sons, Inc.
1,as owner of the proper�y,am exctusively contracting
�rith Iicensed contrectors to conctruct the project MAIL
(Sectio�704a,pusiness and Profe55ion5 CDde). A��FESS 1698 Greenb_riar 1,2IIH_��{224
CONSTRUCTfON LGNUINC AGGNCY CtTY Brea TEL.NO. 529-81]O
I hereby affirm Ihat [here is a mnstruction lending agency � - - -
for the performance of the �vork for�vhich this permit is CONTRACTOR Summit Sheet Dfetal Co. IIIC. � � �� . � � �-
i�sued(Sec.3091,Civ.C.). 'L1811 B61SI1j.T0-ST. -
Lendet'sName ADDRESS �- � � � � � -
Lender's qddress aTv �Ha�vaiian GardensTE'-."o. 527_ggb3 �
I certify ihat I hsve read this application and state�hat the STATE �Ic.
sbove infnrmation is correcL I agree to compl5'�+'ith aIl County LICENSE NO. L9S93Z CLASS -C-43 . .. ._ . _. . . . .
ordinances and State lawx rrgui�ting Heating,Vrntiluting and
Air Conditioning,snd hereby authorive represent�tives nf[his S1:Ii RHVF,ItSfi POR EXPLANATORY LANGUAG4: . � - � .
Coun[y to enter upon 1 e sbove�mentioned property for �
i�u,ectio purpose� S�lfi�83
gn rc af� Da�e .
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