HomeMy WebLinkAbout1590A (9) 4VORKGRS'CORiPGNSATIO:V I)fiCLA1tATION � � 76.4364C � �PP L IC A I I O 1 tl �O R f-E R I VI I 1 �
( herchy af(irm that ! hace a�certificate ot consent to seif
CE-918(2-801
insure.uracertificatent�VorkeriCompensationlnsurance,o� HEAT�NG-VEMTILATING-AIR C�NDITIONING
s certifiea copY th�e�rjenf($ec.3800},Lab.C,�.)/� 'J�T{
1'nlicyNo.��1G_Company.(�P''nL1—�1 Unl� -lW�^'
� ❑ Ccrti�zd copy is here6y furnished. COUNTY OF LOS ANGEIE$ l,SO' sU1LDING AND SAFETY
P l c� 00
Certitied copy is fited with tht counri'buildinS�nspection FOR APPLICANT TO FILL IN �� eui�owc `��� Pe �j`r
d�P'�ar m�nLy� ���.,M ADDRESS �e LF? ,
D�te�1�J�00������-��`�+'�'-�V-'-- (P�INT OR TYPE ONLY) ^
LOCALITY 1 '�/} �
CICRTIPICATE OP LXF::I1PTIVN fRO�t�vORKliliS' NO. TVPE OF APPLIANCE OR[QUIP1.7[NT FEE S!1`^��--uJ�=��
CO�1PF1dSATION INSUR.ANCIi , NEAREST }
CROSS 5T. a
(This section need not be completed if t}ie ��•ork involr•ed ARSOFPTION UNIT,BTU �
by the permit is for one hundred doilars (5100)or Iess.) oisrmcT n�o. � vaoce�SEO B� U
1 cetify tha[in the pr�formance nf[he work for���hich this ' AIR HANOLING UNIT,CFM 2� � _
D
permit i5 issued,f shall nn[emplay any prrson in any mancer �
5o as�o beCo(ne Su6jeCt[o Ihe 1�'nrAers'C�mpensati�n L�ws• BOILEf7,FiTU qppROVJ+LS DATE .+EC'.OR'S51GNnTUn£
r �O�tDo� I b � _ W
D�te Applicant � 1 CO��PRESSOR,�TU_ ROUGH �l _ _ �� z
NOTICE TO APPI.ICANT:If,after making[his Certificate of VENTILATION SYSTEM FINAL v�
lixemption, you shonld become suM1jrct to �he tVorkers' �
C��mpenx��inn provisinn5 oi'ihe labor Codc,ynu muct forth- EVAPORATIVE COOLER VALIDATION
with c�mply with such provisions nr �hit prrmit shall be ,
�le�me�ltev��ked. FURNACE: FAU 1�AoT�_ 1(1 '�b
LICLNStiDCONTRACTORSI)F.CLARATION FLOOR: �s7U�ro, LU
1 hertNr effirm 11tat 1 am IicenSeA unArr rtnv'�SI�1150I�Ch�Pttf HEATER: SUSPEND£O UN{T '
9 (mmmencing�aith Section 70�0)of➢ivision J of the I3usi- WALL
s and Prntex�iona CoJe,and my licence is in full(orce and I � �� O
ct. z ^
i ense Number=����� Lic.Clsss 4'�
�nntr�ctor��u.�.1N��Date_��Z�� -
� 1 am exempt (rnm U�e licensing requirements a5 1 am a
ticensed architect or a ece stered orotes<ionat enginecr p{an check fee 25',0 of above. �1 5 9,0 A
acting in my profession�l ca0acity (Section 7051, IIus- pERM�T ISSU��1G FEE$ I O � �
iness and 1'rofescions Cnde). �
Lia or ReF.No. Dete TOTAL FEE
J��1— #. . . . .g
IIOM1fI;Olt'NI?R-t3Ull.pFli DECLAI2�ITION pLAN CHFCK APPL�CANT � � �I • •F�O O
1 hereby affirm that ! am erempt from-the Contractor's NAME • � •J.r.1 J��
License La�� for�he follmving reason (Section 703I.5,[tusi-
ness and I'rnfes�ions Cndr): ADDRESS �
� I, as owner of Ihe proprrty.�cill do the work and lhe ' � O a 3 O_8 3
x[ruc�ure is nu[ intenJed ar n(fercd for sale (SecUun CITY TEL NO.
7044,f3usiness and Prnfecsions Code). � �`Q_1� � (�,���
QOWNER �� ���
i,ss owner of the Droperly,am ezclusively contracting �
�rith licensed contractors to construcl lhe pmject MAIL �/
(Sectlon1044,RusinecssndProfession<CoAe). ADDRE55 �Q_Gf�.e�l�j{r,�;�( �2Z
CITV �<�D/. TEL.NO.
CONSTILUCTION LCNDING AGENCY �,� 1,r1 . �
I hercby affirm �hat there is a construction Icnding agtncy t,1 � ��y,., � �
for [he performanee of Ihe �curk for w�hich Ihis permi[ is CONTRACTOR � �Vd�Z�Y' 1Y•v
isiueA(Sec.3097.Civ.C.). ��
I.ender'sName ADDRESS � �!1 ���,� �,�
'/� ' 11
Lender's AAdresc CITY ya�����` TEL.NO. �31.{-a�(
� l l� .
1 certity thst {hare re�J this a4>Plication anS state that the �TATE � ��C• .
abovc information is rnrrect.I aeree ro mmply a'i[h all County LICENSE NO. S CL.455 ��p
ordinance5 and State Ism's regUlsting Heating,Vemilsting:md .
Air Cnnditioning,and hrrcby au�horize represrntatives of this SLE Ri:VfRSG FOR GXNLANATORY LANGUAGG � . -
County tn enter upon lhe obove-meMioned properly fnr
i�ispec'i�1,!1r(+ns s. � ���� . .
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