HomeMy WebLinkAbout1289A (6) \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
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