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 -
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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 � � -
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