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HomeMy WebLinkAbout1590A 14'ORKGRS'COhfPGNSATIOVPfiCLA1tATION � � 76A364C �PPLICA I IOItl �OR PERIVII 1 � CE-818(2-801 ( herchy af(irm that ! hace a�certificate nt cnnsent to seif insure.uracertificatent�VorkertCompensationlnsurance.o� HEAT�NG-VEMTILATING-AIR C�NDITIONING s certifiea copY therenf(Sec.38007,Lab.C,�.)/� 'I 'J(�7�{ 1'nlicyNo.���ComCany.(�P''nL1—�1 Vnl� -7`-"".^,' � ❑ Ccrtilizd copy is hereby furnished. COUNTY OF LOS ANGEIE$ t�SO^ BUILDING AND SAFETY P l ct 00 y��-y�/�Ct�rtificd copy is fi�cd with tlx counri�building inspection FOR APPLICAIVT TO F�LL IN qDIDRESS 1 p 1 7 Pe�.ce-4'vl_I�ill� 11 d�r'�ar m�nty. � ���.,M D�te9 1�J�00������-��'-"�'-�V-'-- (P�INT OR TYPE ONLY) n LOCAL�TY l�f CICitTIPICATE OP LXE:IIPTIUN fRORt IVORKliliS' NO. TVPE OF APPLIANCE OR[QUIPh7[NT FEE �����c1Y-�-L NEAREST } COUPF.1dSATION INSUR.ANCIi , CROSS 5T. � a (ThiS 5ection necd not be completed i�the �t'otk invol5'ed ARSORPTION UNIT,BTU � by the permit is for one hundred doilars (5100)or Iess.) oarmcT n�o. � vaoce�SEO B� /��, U 1 cetiCy tha[in the pe[formance�C[he�vork for��'hich this ' AIR HANOLING UNIT,CFM A�/ 2 - ��— p permit i5 issued,f shall nn[emplay any person in any mancer � 5o as�o beCo(ne Su6jeCt[o Ihe 1�'nrAen'C�mpensation L�ws• BOILEfi,FiTU qppROVALS DATE .+EC'OF'S51GNaTUnE �O�tDo� I b � _ W Date Applicant � � COMPRESSOR,�TU_ ROUGH _ _ �� z NOTICE TO APPI,ICANT:If,after m�kinF[his Certificate�f VENTILATION SYSTEM FINAL � lixemption, you should become suM1jrct to ihe Norkers' � C��mpenx��inn provisinn5 0�the l,�bor Codc,ynu must forth- EVAPORATIVE COOLER VALIDATION with c�mply with such pmvisions �r �hit prrmit shall be , �le�me�l�ev��ked. FURNACE: FAU 1�POT�_ 1(1 �b LICLNSfDCONTRACTORSI)F.CLARATION FLOOR: �s7U�ro, LU 1 hertNc effirm IN•at 1 am IicenSeA unArr provisinns nf Cfiapter HEATER: SIfSPEND£O UN{T ' 9 (mmmencing�aith Section 70�0)of➢ivision J of the F3usi- WALL s and Prntex�iona CnJe,and my licence is in(uli(orce and � - . L �� � ct. z /� '�p-� v`:j i j���1 A i ense Number=����� Lic.Class l-'�✓ �ontr�ctor��u,�.1L1y��Date_��Z�� - � 1 am exempt (rom U�e licensing requirements as 1 am a ticensed architect or a ree stered orotess�onat enginecr p{an check fee 2540 of above. �1 5 9,0 A acting in my profession�l cavacity (Section 7051, IIus- pERh91T ISSUING FEE$ I O � � iness snd 1'rofescians Cnde). . � Lia or ReF.No. Dete TOTAL FEE J��J— #. . . . .g IIOM1fI;Olt'NL?R-I3UII.pFIi DECLAI2�TION pLAN CHECK APPL�CANT � � �I • •F�O D 1 hereby affirm that ! am eremp[ from-Ihc Contraclor's NAME • � •J.r.1 J O� License La�� for�he follmving reason (Section 703I.5,IIusi- ness and Profes�ions Cadr): ADDflESS � � I, as owner of Ihe proprrty.�cill do the work and lhe ' � �a 3�-8 3 x[ruc�ure is nut intenJed ar ��(fercd for sale (Sect3on CITY TEL NO. 1044,f3usiness and Prnfzcsions Code). T �`QI 1� � (�,��� QOWNER � �� �y`� i,ss owner of the Droperly,am ezclusively contracting � �rith ticensed contractors to construcl lhe pmject MAIL (/ ��j G��e��,r �ZZy (Sectlon 1044,Ausinecs snd Profession<CoAe). ADDRE55 110 � CITV �<�D/'. TEL.NO. CONSTILUCTION LCNDING AGECICY �J l,Yl . � I hercby affirm �hat there is a construction Icnding agtncy t,1 L � � CONTRACTOR ,�c-�•� for [he performanee of U�e �curk for w�hich Ihis permi[ is .PvaW` i�SueA(Sec.3097,l'iv.C.). I.ender'sName ADDRESS � �!1 ���,� �,� '/� ' 11 Lender's AAdresc CITY y������` TEL.NO. �31.{-a�( � 1!� ,-,l' I ceriity th:�t {hare reaJ this�nM���eton and state that the �7ATE ') ��C• . above information is rnrrect.1 aeree t���mply ai[h all County LICENSE NO. -LS��� CL.455 ��p ordinances and State Ism'S reRu��rting Heating,Vemilsting:md . Air Cnnditioning,and hrrcby au�horize represrntatives of this SLE Ri:VERSG FOR GXNLANATORY LANGUAGC � . - County tn enter upon lhe obove-meMioned prnperly fnr i�ispec'i���r(+ns s. � ���� . . I Signati. F Prrmittee Uate � � - i /-� � ' ' ... . ' � 1'J � .. ..� . � - + / �� / `�. .. . - . -.... . t{ --, � �.li, � Z .'" N � '9 , � . _ . . . . - ' .:'_ _'1 � • �. 9 �- . N , 2 _, O ' i m - . y _ l ` . _ - ' � � � . � . �- . N _ _ 9 - m c'> _ ... O • - � v�i _ � - - p -�I - . m -- ., `_ ' tn � . . b n� '� � o n c 4 � �� � �b�� `' ° q,c'_`Q[^ Mcc � ���., ��cc � ccA `�� ,�tr,o2M � � '� c � _ H �, ,. ' ' ' Z 4� ^ �: ^.Q��� C..J �'� � ^ .`'i❑�^ A ^' ` �. `0 '� n'= � ', ^a c - ti n C � .. � C .'�.' �' p � � . 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