HomeMy WebLinkAbout1292A \5'ORKrRS'COMPLNSATION DIiCLARATION � � 78A384C � _ �
I hereby affirm that I have a cenificate of consent to 5��f � �E-a,g�2-ao, . A P P C IC AT I O N FO R P E R I�i IT
insure,or a certificateof�Vorkers'Compensation In<urance,o� HEATING-VENTILATING-AIR CONDITIONING
a certified copy�hereof(Sec.3800,Lab.CJ
Pnlicy No.�Q6—$�Company_.�tr.'i�E:_.C.41IljL.�I1fi.._�IriC� � � '
❑ Certilied copy is herehy furnished. COUNTV OF LOS ANGELES Tra� 32576 BLot�23G AND SAFETY
� Certified cupy is fikd with the count}•huilding inspection BUI�OING
d"eq,rt 'e �. �: �' ' FOR APPLtCANT TO FILL IN ,aoo�Ess 1865 Pelceful Hills Road
n�cr_L1�3 ,��,�i;�a„� SUi10[1�t SI]eeC MEt.1I;CO. fPRINT OR TYPE ONLV)
�t LOCALITY
CIiR71FICATii OG LREMPTION FRO>1\VORKGRS' NO. TVPE OF APPLIANCE OR E-QUIPMENT FEE
CO�1PIiNSATION INSURANCii � NEAREST }
(This section nced no[be completed i("tlie��i�6rk involved ABSOFiPTION UNIT,BTU CRoss s7. Q,
by Ihc permit is for one hundred dollars (51Q0)ur IeSsJ oisrmcrNo. PnocEsseoer V
I certify tha[in the pe�fmmance of the�work for which this AIR HANOL�NG UNIT,CFM . � � �
permit is issued,1 shsll not employ any person in any manner Q -
so ax tn become subject to the R'orkers'Cnmpensotion Laws. BDILER,BTU �
� APPROVALS OATE '.>PECTOF'SS�GNATURL U
Date - APpiicani . � • W
COMPRESSOR,BTU ROUGH D N
NOTICli TO APPLICANT:If,af[tr making ihis Certifica[e of VENTILATION 5YSTEM �} Z
F.Yemption, you shvuld become suM1ject to the 15'orkers' 1 I ( FINAL — �P/ ��
Comprntation provisions oF the Labor Code,you mu5t fnrth• �
w�m comn�v �.�+h s�cn p�o�[s��ns ->. e!:i• ,^,orm�c shali br F`1!iPOAATlVE COOLcr, VALIDATION - ,
deemed rernkeJ. �
FURNACE: FAU�GRAVITY .
GICCNSEDCONTRACTORSDECLARATION FLOOR� BTU
1 hereby affirm that I am licensed under provisions ot Ch�pter HEA7ER: SUSPENDED UNIT
9 (commencing with Saction 7000)of Division 3 of the�usi� wALI �
ntss and 1?ofessinns Code,snd my license is in fuil force and
t.
f icense Numbrr 19_.�93� Lic.Class C^43 �
c�,���, Su�.�nit Sheet��f�,tal 8/16/83
� I am exempt from the licensing requirements as 1 nm s � �, �9�p
licensed architect or a registered professional engineer Pian check fee 2546 Of e�OVC.
actin� in my prnfessional capa[ity (Section 7051, Bu5- �
iness and�'rofessions Code). PERMIT ISSUING FEE$ LQ SO �j,. � .'. .8
�.ic.or Reg.No. nate TOTAL FEE 16 50 I • • 1 fi 5 0
HO\1E 01CNI�:R-I3UILDLR DFG.A1tATION pLAN CHECK APPLICANT � ry
e • e � i.l J v.`-J
7 hereby affiirm that 1 am exempt frnm'[he Con[ractor's NAME Su�nit Sheet Metal Co.� IT1C.
License Law for Ihe fnllowing resson (Sec[ion 7031.5,Busi- _
ness and Protessions Codz): ADORESS 21811 Belshire $t. Y�
❑ �.�, �������� or tn��.�Fr�cr,�+u a�tne��•ork and the CITY Hawaiian Gardens TE�.No. 527-8863 0 A 1 9"=8 3
s[ructure is not intended or affereA for sale (Sec�ion
7044,Ausinen snd Yrofessions Cade). �
❑ OWNER ri. S, Rrock & Sons Inc, . .
1,as owner of the pmperty,am ezclusivcly contcac[ing
rvith licenced contractors to cons[ruct ihe projett MAIL
(s����oo�oaa,Ousineas and I'fote551ons Code). LIODRE55 1698 Greenbriar Lane, �i224
CITY $reg TEL.NO.
CONSTRUCTION L1iN�ING AGENCY .S�L9--HZ7O
I herebY a(firm tha[ Ihere is a construction lending agency .
for the pertormance of[he �vork for���hich this prrmit is CONTRACTOR S��,t Sheet Netal Co. ISl �- �
issued(Sea 3091,Civ.C.). � � �
Lender':Name ADDRESS 21811 Belshire St.� � - - �
�e�ae��:nee�ess ciTv Aawaiian GardensTE�."o. 527-8863
1 certity[h�t 1 have read Ihis application and 5tate ihat the �—
❑Fove informsti��n is eorrect.I agree to comply�rith all County L CENSE NO. 19S93Z C ASS C—�i3 . . . .
ordinances and S�ate 1a�5�s rrgulnting Htating,Ventila�ing and � - � -
Air Cnnditioning,and herehy�uthorizc representatives of lhis SGIi Rf:VERS�I'OR iSXP[,AYATORY],ANGU,4GIS �
County to entrr upnn the aboce-mentioncd property fur - • - � � -
in pec onpu puses.�
� 8/16/83
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