HomeMy WebLinkAbout1289A \VORKERS'COh7PL•NSATION DECLARATION �76A364C �� � � �
I hereby affirm that I have a'ceniticate of cnnsent to selt CE�878(2-80) A P P L I C A T I O N FO R P E R IM IT �
insure,oracertiBcateof\vorkers'Compensationlnsurance,oi HEATING-VENTILATING-AIR CONDITIONING
u certi(ied copy thereof(Sec.3800,Lab.CJ
Policy No..��$Z..Company_.S_C3Ce Conp. Ins. Fund - - - � �
COUNTY OF LOS ANGELES BUILD�NG AND SAFETY
� � Cer[ified copy is herehy fumisheJ. TT2Ct 3ZS7F) I.Ot 20
� Cerii(ied copy is Cled�vifh the rnunty huilding inspedion BUI LDING
pde��ar�t^J ent. FOR APPLICANTTO FILL IN 1893 Peaceful Hills Road
DshV/LVL�Applicant SlliRlll�t Sheet �tEtal CO IPFINT OR TYP[ONLY) ADDRE55
- LOCALITY -
CliltTll']CATG OP GXEi91PT10N FR09115'ORKLRS' NO. TYPE OF APPLIANCE OR EnUIPMENT FEE
COh1PHNSATION INSURANCL' NEAREST �,
(This sectiod need not be comp�eted if We woTk involved ABSORPTION UNIT,BTU CROSS ST. � d
hy the permi[ is for one liundrecl dotlars ($100) or IessJ oisra�crNo. vaocesseoov �
1 cer[ify thst in fhe performance of[he���ork for�vhich ihis n��HANDLING UNIT,CFM /i� t/ �
// 77AJ
permit is issued,f shail not employ any person In any manner� � ��� L_l�` O —
so as to become subject tn the\5'orAers'Compens�Hon Laws. OOILER,BTU --- U
pPPROVALS DATE IN5'_CTOR'SSiGN4TURE
Date Applicant � COM19PRESSOR,BTU ROUGH l,[� N
NOTICI[TO APYLICANT:If,after maAing this Crrtificste of � (}- VENTILATION SVSTEM 'L�{ OO FINAL A J -� 2
Exemptinn, yau should hecnme subject to the W�xkers' < � —
Cumprnsstion Drovisions of the Lahor Code,you muet fnnh- �
with comp�y wi�h such provisionz or this permit shali he � EVAPORATIVE COOLER VAUDATION
deemed revnked.
FURNACE: �FAU—GRAVITV
LICENSED CONTRACTORS DECLARATION . FLOOR� eTu
I hereby affirm that I am�icensed under provisions of Chapter HEATER: SUSPEN�ED UNIT
9 (rnmmencing�vith SeCtion 7000)nf Division 3 of the Ifusi- WALL
ness and Prnfessions Code,and my license is in full fnrce and
effect.
�icense Numher i9$932 Lic.Class C-G3
tractor Summ3t 5 ff pate 8/16/83 ��2 g q p
�1 am exempt from ihe�licensing requirements as 1 am a ����'�•� � �8 4
lirensed architect ar s registered professional enginecr Plan check fee 2546 of above. � (V
acting in my profezsional npscity (Section 705L Bus-
iness and Professions Code). � PERMIT ISSUING FEE S iQ SQ • � • •3 Q..S�
Lic,or Iteg,No. Date TOTAL FEE 3(1 SO •-• a J n,J Q c=i
HO\tE 011'NER-DUILDFR nGCLAIt.AT10N PLAN CHECK APPLICANT � �
[ hereby a(firm Ihat I am exempt from-ihe ContractoPs NAME Su.*.nnit Sheet Pfetal Co. It1C. ���� Q—��
Litens¢ Law for Ihe fnllowing reasun (Section 70J1.5,IIusl- °----
ness and Professions Code): ADDRESS 21811 Belshire $C. ,y�
❑ i. �g mvner of tlie proprrty,will do the��•o�k and the cirv Ha��aiian Gardens TEL.NO.SZ7—HHG3
strvcture is nnt intenJed or offered fur sale (Secfion `
7a44,Business and Prnfession:Cnde).
OWNER ,�,� . J, grock 5 Sons Inc.
� I,as n�vner uf the property,am exclusiveiy contracting- __e_. .
with licensed rnntr�etors to ennstruct �he project MAIL -
(Section 7044,�usiness and I'rofessions Code). ADORESS 1698 Greenbriar 73R@. �ZZ�f
" CONSTRUCTION LIiNU1NG AGLNCY
cirv Brea TEL.NO. SZ9—HLJO
I hereby a(Grm ihat Ihere is a cnnstructinn lending sgency '
r��r ine performance or tne «�o�� r�r �.�,��n rn;: �rrm�r �s CONTRACTOR Smnmit Sheet t?etal Co. Ine.
issued(Sec.3�97,Civ.C.). � � � - �
Lender's Name ADDRESS 21811�Belshire St. - � - -- � �
LrndePs Address CiTY TEL.NO.
ftawaiian Ga�dens 52Z-88
I certify[h�t [have read Ihis appiication and state that the STATE I95932 L�C. �
aboce inform�tion is correct.1 agree to comply a��i�h all County LICENSE NO. � CLASS�C—�i3 . ... . . _
ordinances�nd State lae•s regulating Heoting,Ventilating and
Air C��nditionin¢,and hereby authoriie reprrsrntativrs of ihis SIiF•.R1iVlil2Sti GOR EXPLANATORY LANGUAGL - . _ ._ . . ...
Cu n�y to en[er upan he above-mentioned propetty fnr
in5 ction purposrs.
�/d,/ 8/16/83
Sig ture of Permitiee Date
i � ��. -_. -_. . __.
. ^ . .
�-�, -_ �
�� � : . �_
z -. . ,. .
N . . �-
L
R1 . . ' . . }....
� i
0
p
N
Z . �
O .
-1 -
N - .,� `_
C�
L :��� ,�J
.'l ✓
� - . .,: '-^ . � � � .
1 i-.1 •
' -' � �
N
m
. _ '--� � �
�: J O
. �
,t N
. -,� O
• - ` m
� _ „ N
- .y
� ��
�
. � �
�! ,.
� � a"�a.Y ta r r,
� A ,v �b�j�PF^.'��n _
� ... ... L^ �^ �. - C �� rt;`C n � O .-. O %� ,�-,.7 io•��' .
_ � p� q�F+ � � .n ^'? ""' n ^a�ra'�" : � �'C-'y S'o �, .
c n �,��'e C ^ � -�. �•�� ,a - ti " .
' � e'b ..: S� "' M1.ti " ,.-. v. � C �. ''> � �n r= 0
. � p q � 1 C''�' w� C ..,o; O �' `i- t^�O n ' �,..� �' � � '^ 4 �~ 'A p Fr.,v 1
� � � .� �. R: . ' .: - C y. � � �p 4 .. 1-0 C C' � <'
.y,, , p d � � � y � N:,.C.,,�' �C e.�i h i.� �!��,n �oc°,m `�'���� �y= = , 7_
� './ -= fL C~Y~C^ sa ..� � � �C ;o � C " c y C .....ic y+ p C'1
� `� � i �'' c � i%.c —�_�'�.c Q,� m� � ��,� ^ �� " n�c, p �'" 3 'y
n � n �„ -� . � ' �� � rc - o ^ � fi c .a�, ~ 'I`. •-•^ '" �
/ . � �+. n n �'n Cy^. -Jr'. `� � - ' �ti a .�. P 4 �C�^..a.o b N (; .�'.~ � .
..,. � � _ . n � C ` -'q`'.i: � �o C � i~�. c `^ .'. '�• ��0., p y ^ "�+� _ C C�• l�.
� � �� �r � G G.� '�" _� 1 4�- �Q� `�N U -. p"�� � h � C .
- � ' �` �., = A ti ��:O .. C G. � p c . '-� � _c; O CT1
. i,• Q. f.,�C G p �- � ' C �. :� � 2�'� tr o - C �� O n �' `�
. . � . � 4 V �, p � : � � C '^ �� � �O C'� � � P�n
. . . V. Cl' y ' f-C' C^ p � C�^ ' � .�_f `•r �,q,�v'�i v O �Ua .. d
U (; r. 'y� ' �
. C � h=:.'O C ?C v - O�-tia C��^,., ^ Y b i` q •�O t^" a ry h ' �^ !�
. ��� n`^v JI ��'..� q r � ` �, . =b���1 �`o �� _ � r'
;� . h C "� ��, c+-. C �F, 'u t n rV�•.`" C-" �:�q�,,�J'�t�'� ti • y�. i
. � c� ;� ��=y-c �-. ti � n O n�G C n r. � S�C i O � �= ' /
� ~ r, : �-�' ' O C ., ~� � �."'A ��'" :. ��c � r� ^'�
� `n n C n.� i . ...o �L� � � c� r ^.,h ti `c'f7"� O
o b � a �., _ a � p
c o a � � ° �a �- � `' o� y.^n - _ v 5�' 7 .
"`. ` � � " � n "' � C x o y O c o c,.J �'"q � o-.0 � e, �r�
' , . ' �'C C .y� � � ..; ..' " �` :. :c O'C C`'�' 4'O = �r.
. - �,e. rt C :. ^ r. � �.,� �.. c _ .,,p
�A� 'o � � z c � C,^.: n � �. S- �.< � � � " �,
. n in� � C~ �, ^ � � p � �o� p = '�'' "'
. �, � C r'C " C _ r�= F .. :'`c~ i� . .
-- . 40�+�^ ' n ��`y � .
' . `_��,�_��----"��.'�.��
s�—