HomeMy WebLinkAbout1290A \VORKLRS'COhiPiNSAT10N DECLARAT[ON 76o.364C � �
1 hereby atfirm that 1 hare a'certiflcate of consent to self �E.e,e�Z.So� A P P L ICAT I O N FO R P E R i�Ji IT
insure,oracertifica�eoflVorkers'Compensationlnsurance,oi HEATING-VENTILATING-AIR CONDITIONING
s Certified copy thereof(Sec.3800,Lab.C.)
�,oi;�vh,,. 306-82 Company State Comp. Ins. Fund
� � Certified c��py is herehy furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Tract 32576 Lot 21
� Certified copy is filed wi[h Ihe cnunty�building inspection FOR APPLICANT TO FILL IN eui�DING
�`/���`��' Summit Sheet Metal Co IPRINT OR TYPE ONL�') Aooness 1885 Peaceful Nills Road
Dste Applican[ .
LOCALITY
CERTIF,ICATE OE'EXEpIPT10N FROA1 l5'ORKER$' NO. TYPE OF APPLIANCE OR Ed111PMENT FEE
CO�tPENSATION INSURANCE NEAREST }
(ThiS section need not be completed if t6¢ tv0�k irlvOiVPd ABSORPTION UNIT,BTU CROSS ST. O
by the permit is for one hundrrd dollars (5100)or less.) DISTRICTNO. PROCEASSEOBV U
f ccrtify that in the perfnrmance nf the worA for which this AIF7 HANOLING UNIT,CFM /f /'� �j O
permit is issued,I shall not employ any person in any manner O( L Z7f�1 _
so as to hecome subject to the\5'orkers'ComPensation L�ws. E301LER,BTU
APPROVALS DATE �N ECTOF1'SSIGNATUFE W
Date Applicant COMPRESSOR,BTV a
ROUGH ���I �� tA
NOTICE TO.4PPLIC.4NT:If,after making this Certificate ot � VENTILATION SVSTEM �"�j� Z
Iixemp�ion, you should Fecnme subject to the Norkers' 1 6 OO FINAL � �y� l—
C��mpencatinn provicinnc nf�he l.ahnr Cnde,you muct fnrth' - I f�' --
with cumply ��ifh such pro�isions or ihis permit shall 6e EVAPOflATIVE COOLER VALIDATION
deemeArevnked. � FURNACE: FAU—GRAVITV �
LICENSGDCONTRACTORSDGG.ARATION FLOOR� BTU
I hereby offirm that I am licensed under prnvisions of Chapter HEATER: SUSPENDED UNIT
9 (mmmencing with Section 7000)nf➢ivision 3 ot ihe Rusi- WALL � '
�k�anJ Prntessions Code,and my license is in full torce and .
���Zct.
t.:.�se t�lumner 19$932 Lic.C�ass C-43
Contractor SU1fII7�t 5 P1 Date 811fi�$�
� I am exempt from the licensing reyuiremenfs as I am a °� 2 9�O A
licen:ed architect or a registered professiunal engineer p�an ch0tk fee 259'o of above.
acting in my professional capscity (Se[[ion ^OSI, Bus- i:�• • •�• °8 .
inesx and Pmfessions Code). � PERMIT ISSUING FEE S 10 $0 �
Lic,or Reg.No. Date TOTAL FEE . LG SO �`•�•�� �5�
Sf0\1I:OR'N1iR-T3IfILDRR DP.CLAR?.TION PLAN CHECK APPLICANT • •'�1 G 5 p�
I hereby a(firm �n,� � ,m exempt from�ihe co���3���r�s NAME Snr.m�it Sheet Metal Co.
License Latv for ihe fnllrnving reason (Section 7031.5,Eusi- —D—�C� ' Q a� 9—8�J
nessandProtessionsCode): qDORESs Z1811 Belshire St. -`
� 1, as o�vner of the property,wili dn the�vork und the CITY TEL.NO. �
structure is nnt intended nr otfered tur saie (Sectinn HH�raiian Gardens 527-8863
7044,Rusiness snd Pr�tesxinns Code). � OWNER �}���'#�i��4h��t�*ai�.rf. J. Broek � ons, Inc. �
� 1,as o�e�ner of the proper[y,am ezdusively contmcting
with licensed contracmrs to construc[ the project AD�RESS 1698 Greenbriar Lane, �224
(Section 7044,Dusiness and Prafessions Code).
CONSTRUCTION LISNUIKG ACENCY CITY Rrea TEL-NO. SZJ�HI7O
I herebY affirm ihat there is a consiruction lendi�g agency CONTRACTOR T - '
for the performance ot the �vork for which this pennit is Summit Sheet D.etal Co. 121C. .. _
�5:�ea�s��.3097,c��.c.). 21811 Belshire St.
Lender's Nsme AOORE55 � � �
Lender•s AdJress eiTv HawaiianGardens TEL.NO. SZ7�HSE)3 � � � � - �
1 cer[ify that 1 have read this spplicstion and state ihat the STATE UC.
ahnve inform�tion is correct.I agree m comply�vith nIl County ueen,se No. 195932 CLA55 — � . . . -
ordinances and State laus regulating Heatin6.��entii��ing and � �
Air Conditinning,and hereby�uthorize reptesentatives of this SEF,RT•,VGRSF.FOR F.XPLAN.0.TORY I.AVGUAGF. � �
Cuuqty to en[er upo the above-mentiuned pruperly for _ -
ii spe on purposes.
.ig atureoCPen i[tee Date 8 � .. . . . . _. . . .
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