HomeMy WebLinkAbout1591A � 14'ORKHRS'COStI'I:NSATION DGCL,.a,�T�oN � '6"36"° �P P L IC AT I O N FO R P E R i�fi IT' �
I hrrehy affirm th�t I i�ave �certiffcate of consent to setf CE-II18(2�901 /7
insure,or a certificate ol Rbrkers'Compensation Inturance,oi . HEAT�NG-VENTILATINGAIR CONDITIONING
a certified�/c}a�pIy�fth�e1refiof(Sec.3800,-7La�b.C.)V1,, �1 �„J
Poticy`J��4�2`DSA_C�mpsny—G���4\�S`"� U(ll� -l��
❑ ez.�irra���y is hereby furnished. COUNTY OF LOS A'VGELES BUILDING AND SAFETY
P 30o y�so=,.y
Cerufied copy is filed«�ith the county huilding inzpectinn pUl�DING / � � y�
r�CJ1p'��/��,,/� FOR APPLICANT TO FILL IN nooRess �FSbS QQ���`C.)1 t�L�
I)ate� �e .App�icant_l�L�_Q�X-�1_`�"=S_ (PRINT OR TYPE ONLY) ,/� 1
LOCALITV �,n „�'�/�11 U'�
CERTII'ICATl OF IiXGFtI'TION PROV WORKGRS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE l.W 1wY���`
CO�1PIiNSAT10N IUSUItANCG NEAREST }
1(This section need not bC completed if the «•ork involvCd ABSORP710N UNIT,6TU CROSS 5T. O
l hy the permit is for one hundred dollars (S1D0)or Iess.) ois�RicrNo. vaece seoev V
,i 1 certify th:rt in the perfnrmance of[he work for�vhich ihis AIR HANOLING UNIT,CFA1 �
permit is issued,I shsll not empioy anY pereon in any mannrr �� O.-
so as to hecome subjeC[tn the 1Vorkers'Cnmpensation La�rs. BOILEF,�7U �
� qPPROVALS DATE I � .P'-CTort'Ss�GNArV�E
��(]�'� /� W
�Da[c Appticant � COh7PRE5SOR,6TU_ D�-�/-`-""' �V ROUGH l� y
`OTICE TO APPLfCAN7:If,aCter making Ihis Certificate ot VENTILATION SvSTEM I a+_�� P/ �?
esempfion, you should became suhject to the R'orkers' FINAL ,���,
t�mpensation provisions of the Labor C�de,you must fotth- � EVAPORATIVE COOLER VAUDATION
th comply w'ith such Pro��isions or �his permit shall be �
med revaked. FURNACE: FAU Ry V�ITY � p0
I.1CIiNSEDCONTRACTOR5D13CLARATION � FLOOR� BTU��(}p"0—
-�iereby affirm ihst 1 am licensed under prorisions of Chap[cr HEATER: SUSPENOE� UNIT
�/commendng with Sectinn 7000)of Dicisinn 3 nf Ihe Dusi• WALL �
�a a •J I'rnfessi��ns Code,and my license is in full torce and � �� 7s �
�n(r3��,mner3�5zSN_ �.��.���=s_. -a-.o �/'(�D �
� \!V �..�.��'
nirsctor 3�_N_in��e.s'�Dste_�S''---1_� _' S 9.1 �
�� 1 am exemP� from the licensing reyuiremenis as 1 am a �
Iicensed architect or a registered protessinnal engineer PIBn Check fee 25°0 of 3bove. �.�'� . � m�
acting in my professions)eapaeity(Sectinn �osi, ❑us- PERMIT ISSUING FEE S �� 's0
iness and Professians Code,
� [.ic.nr Heg.Nu. Drte TOTAL FEE �j � • •5,j'Z -r'j
F 1{O�tE O�VtiER•�UIL�FR DECLARAT[ON PLAN CHECK APALICANT � ,�1e e Jr 5 z J cs.r
�
P I hereby affirm Ihat 1 am esempt fmm�the Contractor's NAr.�E '
� ticense Law for thc follow?ng reason(Section 7031.5,IIvsi-
ness anJ Prafessions Cadt): ADDRESS �II'J O-�3
� 1, as o��'ner of l6e prnperty,will d�the�vork ind the � �
structure is not intended or oCfered tor sale (Section CITY , TEL.NO.
7044,IIusiness and Professions Code).
OOWNER �'(� . OG� c ��� • . .
1,as owner of the property,am exdu<ively contrac}ing ���
with licensed contractors to construct the project MAIL ! /.i("/ ��reQ-\„i-�,/` ,�-^7ZL�
(Sec�ion 704J,[Iusiness and Professions Code), nODRESS �D"�d l ••y�LJ� �_ L 1
CONSTRUCTION L1:NUING ACIiNCY CITY ,3re(� T[L.NO.
I herehy afCinn thst Ihere is a construction lending agrncy CONTFi/+CTOR ,.�5�' � - � � �
tor the perfnrmence of ihe�vork for �chich lhis ptrmit is ����� � � � , . _ . .
issued(Sec.3097,Civ.C.). � ' ,
LendePs Name ADDR6SS ( a �, P�C��.�L1�� �� �
Lender's AddreSs . CITV �(��,�/� TEL.ND.�3�-,,�I� . . .
[certify tha[ I h���e re�d �his application 3nd 5[��e tha[ihe STATE LIC. /�
sbove information is correcL 1 agree tu enmpiy�cith all County UCENSE NO. �. CLASS l..�� _
ordinances and S[�te la��•s tegula�inc lieatine,Ventil�ting and
Air Conditioning,and hereby au�horize representotires of this . S1iIi RtiVGRSG POR EXPI.ANATORY LANGUACE . -
County ro enter upon the abuvr-mentioned property for
insp�'nn u pn��
) ss-2�-1-FC3
5ignat nf Permi[tee D�te . . .
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