HomeMy WebLinkAbout1291A (6) ICORRFRS'COUPGNSATIONDiiCLARATION CEAS6gC1280) . APPLICATION FOR �Ef�IH1IT -
I hereby affirm ihat 1 have a cer[iticata of consent to self . � �
insure,oracertifiwteoflVorkers'Compensationlnsuronce,o� • HEATING-VENTILATING-AIR CONOITIONING
a cer�i(ied copy thereof(Sec.380D,Lab.C.) �
f'alicyNo. 3OG—HZCompanY State Comp. Ins' F�nd . .- . . . ..
� ❑ Certitied copy i:her�by turn�shed. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Tract 32576 Lot 22
�•� Cer[ified copy i5 filed with ihe count}�building inspection - BUILDING
dep9rtm �a � FOR APPLICANT TO FILL IN ADDRESS 1877 Peaceful Hills Road
Date�16 83 Applicant Summit Sheet Metal Co (PRINT OR TYPE ONLY)
LOCALITY
CF:RTIFICATG OF GXF.IIPTION FR0611VORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE" '
COUPFNS.ATION INSl1FLANCG NEAREST }
(This SeCtlOn nPPd nOt be completPd i�ihe tvork inv0lved ABSORPTION UNIT,BTU CfiOSS ST. d
by tlie permit is for one hundred dollars(5100)or less.) oisrmcT uo. vaocesAsco or V
[certify that in the perfnrmance nf ihe�vork for w�hich ihis AIR HANOLING UNIT,CFM � � �
� permit is issued,1 shall nn[employ any person in any manner �
so as tn 6ecome xubject[o the\1'nrkers'Compensatinn Latt�s. BOIIER.BTU I— '
- - -� � APPROVALS DATE IN�GCTOR'SSiGNATURE U
Uate Applicant COMPRESSOR.BTU ROUGH '3 d�C� � N
NOTICF.TO.41'PLICANT:lf,after making this Certiticate of 4 VENTILATION SYSTEM Z4 �� FINAL f�Zp� ���� ��?
h:semption, you should becoma suhject to the t�'orkers' _ _
Cnmpensatinn prnrision5 of the Labor Cnde,you must fnrth- EVAPORATIVE COOLER �
}vith cnmp)y with such pruvisions or ihis permit shall be VALIDATION .
deemed revoked.
FURNACE: FAU_GRAVITY .
LICENS[D CONTRACTOItS DtiCLARATION FLOORr F3TU
1 hereby aCfirm that I am Iicensed undrr prnvisionsaf Chapter HEATER: SUSPENDED UNIT
9 (commencing with Sectinn 7000)ot nivision 3 nf the Busi- WALL �
ness and Pro(essions Code,and my Iicenze is in futl force anS
cL
��ense Number i9S932�.ie,Class C-43
c�r�cmr Summ3t S/Tf Da�e $�16/83
� i am ezempt frnm the Iicensing reyuirements as I am s
licensed srchitect or a registered proSessional engineer Plan check fee 2590 of above. ��� 2 9.� R
actin6 in my profestional capacity (Scction 7051, l3u5- � -
inexs and Yrokssion:Code): PERh71T ISSUING FEE S 1� 0 ��!� �i� �8
Lic,nr lieg,No. Date TOTAL FEE 3(y 5Q
I:•:•34 50
110�1E OIVN@R•BU[LDER DECLARATION p�AN CHECK APPLICAN7 - " • �
• • •J Q,;jQ�
I hereby atfirm Ihat I am exemOt from-the Cnnlractor's NAME. CO.� TIIC.
License La�v for[he toliowing reason (Section 7031.5, nu5�- S�3t Sheet Meta.
ness and Professions Code): ADORE55 21811 Belshire St. - � � p$1 0-�3 �
� 1, as o�vner of the proper�y,will dn ihe work and the CITY TEL.NO.
sHuc}ure is nat intended or offered for sale (Settion Hawaiian Gardens 527-8863 �
� 7044,[iusiness and Professions Code). - ----
❑ � OWNER p;, J, �rock � Sons, Inc.
1,as owner of the pmperty,am exclusively contrscting
I u�ih licensed contrac[ors to ronstrutt the project MAIL
(Section 7044,Ousiness and Frofessinns Code). AD�RESS 1698 Greenbriar La_ne, ;�224
CONSTRUCTfON LF.NUING ACF.NCY ��TV BT83 TEL.NO. SL9—HI.7O
�I hereby af(irm Ihat [here is a construction lending agency � T
for ihe rerfolmancC of Ih0 �vofk fUt ��'hictl this permi[ is CONTflACTOF S`ll1T7111t Sheet Pietal Co._�aIS
issued(Sec.3097,Civ.C.). .
Lender'sName ADDRE55-'LiHiL BO�.SII�TC St. � �
Lender's Address
cirv Hawaiian Gardens rE�•"o. 527-8863
I certify that 1 hsre resd this applicstion snd sts[e ihst the STATE 195932 CLASS C—�+3—
ahove intorm�tion is correct.I agree to comply with all County LICENSE N0. . . . .
�ordinances and State lawc rcguluting Heating,Ventilating and
Air Conditioning,and hereby authnrize represent�tives of this - SEE REVERSG FOR P.XPL�NATORY LANGUAGE - . �
County ro enter upon th abure-m ntioned property (or . � • � - � �
inspect'�n p�urpnsec. . .
—_/i'�3"�.,di�- � 8/16/83
Signatu of I'ermitlee Date
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