HomeMy WebLinkAbout1589A �5'OIiKF.RS'CO\iPENSATIOY UI?CLAR.�7'ION 7G�36aC .
I hereby affirm that I have a certific�te nt cnnsent to self �E-$,B�z.flo, . A P P L IC AT I O R! FO R PE R Pf�IT -
insurc,orncertiticatentNorkers'Compensationlnsurance,or HEATING-VENTILATINGl11R CONDITIONING �
a cenif�ed c{n�py�ihre�,re�ot(Sec.7800^,7Lab.C.) �
P��IicY Vo._[.L�2��.+ Cnmpan5'—C_—t�\�� � � � U111� �Q�
� Certified copy is hcreby furnished. ^, ��O COUNTY OF LOS A�VGELES EiUILDING AND SqFETY �
� UI ���'
r'/�/�rrtified cn is filed with ihe county buildin �1�" .
PY �inspection
� d�e v�m��n�t 1n` FOR APPLICANT TO FILL-IN 6UILDING
Date�G`L�}.Appiicant�.1�_ _ _ (PRINT OR TYPE ONLY) AD�RESS,g�5 �ea�Q���LS___
�� LOCALITY �;/� _n� {�/;�f
CI?RTIPICATE OF[XE�IPTION FKO'�t\VOIiKFiRS' NO. TYPE OF APPLIANCE OR E�UIPMENT FEE V•"<�� �—+��1
CO)iFFNSA7l04 iNSURANCIC NEAftEST
(T]115 SFcCtOn nee� not �C camplefed 1(t�tC n'O[k It1Y0�VCt1 AOSORPTION UNIT,BTU CROSS ST. d
by the permit is for�one hundred dollars (5100)or Iess.) oisrnicrrvo. Puecesseoov �
U
I cer�i(y Ih�t in the performqnce of Ihe�vork for n�hich�his AIR HANDLING UNIT,CFM � • �
— pzrmit is issued,1 shali nnt empiny any person in any manner p
xo sx to bernme subjzct to the 1Vorkets'Compensation Laws. BO�LER,sTu - -- � —
� APPROVALS DATE iNsv� �on'SSiG"�ATURE („)
/��y� /� W
D3te Ap(�IlCan[ I COMPFESSOR,6TV—OL�+v`� �/ qOUGN �'
��_ N
NOTICG TO APPLIC.ANT:]f,aRer makind Ihis Ctt[ificate nf VENTILATION SVSTEM p�� — .� Z
Lxemption, you shou�d become suhject io the 15'nrkers' � FINAL —�'-'.t/ f _
Cnmpencatian procicionx of�he Labor Cnde,ynu must fmth- �
w��h romply �vith s���n n���ivo�s or �ncs permit <nan ne evnvoRnTive coo�eR VALIDATiOiJ
deemed revnked.
FURNACE: FAUs�GRAVITY � 00 '
LICENSfDCONTRACTORSDECLARATION F�OOR� eTU_S-0��0_6— �
1 hereby affirm[hat t am lirensed under prnvisionsoCChapter HEATER: SUSPENDED UNIT
�nmmencing�vith Section 7000)of Divisinn 3 of the pusi- ' , t7ALL
i and Pmfrssione Code,and my license is in full force and y �,, 7S
fect. ?��/� �� �3 (/1,��[�� ��
Li�<e-Num6er...2�—?z��'{. Lic.Ciass�_
Contrac�nrl(V�1'(eI��S pate_�Z��
� 1 am exempt from the licensing requfrcments as 1 am a
Iicensed architCCt or a regislered professionai rnginrrr ''� `5 H.9 A
���.n .� n. Plan check fee 25°0 of above.
g profrssional capacity (Section '051, Dus-
iness and 1'rofescions Code). PERMIT ISSUING FEE S '� s� �` � ' '-�8 �
I.ic,or Reg.No. Oate TOTAL FEE � a r "
• •
� ]IO`dti 0�5'NF.R�➢UII.DER DECLAR.qT[ON pLAN CHECK APPLICANT � �� � 5 v 2 J
1 hereby affirm that I am exemp[ (rom-the C��ntractnr's NAh7E • • •)��7 J�
License Latv fot the follow�ing reason (Settion 7031.5.I3usi- -
ness and Professionc Code): ADDR6SS 0�'.3��—�J �t
� f, as on•ner of the property,will do the�vork and the CITY TEL.NO. - J
structurc is nnt intendtd or nCfered for s�le (Section
7044,pusiness and Professions CodC). Ck , _
01NNER �^
� I,as owner ot the property,am exclusively contraeting _��V� � ,
�rith licensed con�rac[urs to conshuct the project MAIL �j�� /'�^� ,^ �
(Section 7044,i3uzines5�nd Yrntessinns Cnde). AOORESS �"J `� ee�.K,Ce.� ����
CONSTRUCTION LBNUINC AGLNCY CITY � e `(� TEL.NO.
I hereby afCirm �h�t there is a consVuc�ion IenJing a6ency �J •
for [he erfonnance nf ihe n�ork for whith tliis rmit is CONTRACTOR ^ I .
� re __i v�����S� � � � . .
� issued(Sec.3097,Civ.CJ. � -
Lender'SNamr AOORE55 �?
�.,o �, Qc�e �co
Lender'SAAdress CITV 1� �hQ`� TEL.NO. 3�I—��I�
� 1 crrtify thst I havr read this applicatiun anJ state ih�t [hr . STATE' + ,�t7r`i� UC. �� . . ..
above inform�tiun is mrrect.1 agree to comply�cith ail County LICENSE NO. �1,.J CS CLASS �
' orAinances and State I�t��s rrp,ulating Heating,Venlilating;�nd -
Air Conditioning,and hereby authori+e representatives of this S�G RLVERSE POR EXPLANATOItY LANGUAGh:
Cuunty to enter upon the aboce�mentioned properiy for � -
inspection pnrpnsrs.
��.�rv� ��2�(—Fr�
Si¢nat r �i Permittee Date
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