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HomeMy WebLinkAbout1592A �. �VORRLRS'CO\tPG'JSAT]ON�GCL,,RAT,oN - - � �6A'64° � A P P L IC AT I O i�! FO R P E R Pr7 I T � � � ] herebY afrrm [hat f have a'cettifica�e of consent to self CE-819(2�80J � insure,oracertificateMR'orkers'Compensa�innlnxurance,ni HEATING•VENTILATING-AIR CONDITIONING a certified tnpy thereof(Sec.3800�,7Lab.CJ PulicyNo. ��t�Cnmpany_C��\� ��\�- �l�b� � ❑ Certified copy is heretiy fumishzd.. 1�� 3��_COUNTY OF LOS ANGELES �S�_ BUILDING AND SAFETY �crti(ied copy is tiled with ihe counip building inspectinn . a1+�.�� � FOR APPLICANTTO FILL IN eUILDING 1 }�'1�. � , Pate�L� Applicant__�O�_ (PR�NT OP T�'PE ONLV) /�ODftE55 I gs� ��� 0 ��� LOCALITV '(� �?�nI� C1iRTIFICATL'OT'IiXF:'�1NT�ON PRO}t IVORKICI2S' NO. TVPE OF APPLIANCE OR EQUIPMENT FEE 7-��w7L�� � . C0511'F:NSATION iNSURANCG NEAREST CIi055 5T. } (This seclion nced not be completed if the anrk im•oh�ed � A6SORPTION UNIT,BTU a by the permit is for one hundred dotlars (5100) or less.) OISTRiCTNO. PP.�CE$eoov V t cerlify that in the performance of the m�ork for which this AIR HAN�LING UNIT,CFM � �/j� � — - permi[is issued,I shall not empiny sny pers��n in any manner �F'� O sn as�o become sufijzct tn ihe\5'orkers'C�mpensation Laws. BOILER,BTU � `Q� APPROVALS OATE in� peroa�sscvnT�ne (� � Date � AppliCant � COMPRESSOR,BTU�01�0 � ROUGH �' �. N NOTICG TO APYLICANT:If,after making Ihis Certificate nf VENTILATION SVSTEM / �� Z F.semption, you 5hould becnme suhject to th8 1Vorke�s' FINAL ' � Cnmpensntion prorisionc of the t.abnr('nde,ynu muct fnrth� with cmnply with such pm�isions or Ihis prrmit shall be EVAPOftATNE COULEfi VALIDATION � deemed re�•oked. } FURNACE: FAU— RAVITY �� . ' L(CCNSLD COtiTRACTDIiS D[iCLARATION L FLOOR� 67U_�.j�Oj�._ �b 1 hereby 3ffirm that I am lirensed under pravisions nf Chap�er HEATER: SUSPENDED UNIT 9 (cnmmencing with Srr[ion 7000)of Division 3 of the l3u5i- WALI � ness and Pmfecsions CnAe,and my licen=e is in full force and ,S � e(feM. �{ �p�� ^ �� e �� � � ]icrnce Number�-IS�\L,_Q�� Lic.Clasc�—^�O ' �trsctoL✓�_�1�Q1J_Qf� Da[e_6_�_!�� U 5159.?_A I am exempt frnm the li[ensing requirements as 1 am a licensed architect or a registered profecsional engineer plzn check fee 25°0 of aboVe. acting in my professional c�pacity (Sect�on 7051,Bus- — O s � � � � � �8 iness and Professionc Code). PERh1IT ISSUING FEE.�i - �� Lic.o�Res.No. D�te TOTAL FEE �3� I • •5 3.2 5 �IIO�tE 00'YHR-BUILDER DECLARpT10N pLAN CHECK APPLICANT . . e a,rj���c=.� 1 hereby aftirm that I am esempt fmm-the Coniractor's NAh1E �_8 3 License Law for the (ollmving r¢ason (Sectian 7071.5,Ilusi- �L�.J ness and Professinns Cnde): A�ORESS � � � l, as nwner of[he properry,will do the w�ork and ll�e CITY TE�.NO. , J � structure is nnt intended or o(ftrcd for sale (Section � 7014,�usiness and Pr�fessions Cude). ^raGS^ < eT U*� � I,as n.vner of the property,am exclusiveiy contrac[ina OWNER � with IicenseJ contractors tu conshuct the prujeet h1AIL �Z�i/ (Section 704J,Fiusiness and Nrnfessians Code). A��RESS `�� -,re�. b���� �l CITY Q� TEL.NO, CONSTItUCTION LtiNUI4G:1GGNCY �(� 1 hereby affirm Ihat (here is a cons[ruc[ion lendine agency ;� ��� : I�,�� foi the perfnrmsnce oP Ihe «�ork fnr �5�hich �his rttmit is CONTfiACTOFi f 4 issued(Sec.3097,Civ.(;,). . � Lender's Name ADORESS �t3o �_ .p�.���co , ' Lender'sAAdress CITY ',�„�n,�'�� T[L.NO. �2 ��,� >>..�_ �t.v 1 certif}' that 1 have rcad lhis application and state tha[}he STATE �� �I LIQ ^� ' aboce information ic correct.1 agree to mmply n�ith all County �ICENSE NO.. ,.� ZS I CLASS �OiO - • ordinancrs and Stste la«�s reRulatinR Heating,Ventil:�ting and � Air ConJitianing,and hereby autliori�e repre�entatives oC this SEG REVERSIi�OR IiXNLANATOIiY 1,AtiGUAGIi County to enter upon the aboreanentioned praperty for - � � � � inspec�i�n urpo-�s � ��_��{..��rv� �S-2�I-��,3_ ISignawre Permittee Uste �: � . _ _ � .M � �' � � . � . q , .__ o ' � � � , " - _ _- N - - � __ . '' O ' ; - . R, . . 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