HomeMy WebLinkAbout1588A R'ORKERS'COAIPF:NSATION Df[CLARA7ION � 7fiA�G4C �
� hereby a(rrm Ihat 1 have a certificate of cnnsent tn selt CE-818(2�801 A PP L IC AT I O N FO R P E R I�l1 t �
insure,oracertifcateof\Vorkers'Compensationlnwrance,oi � HEATING-VENT�LATING-AIR CONDITIONI�lG
a cer[ified(c�opIy rth'e�r-/enf(Sec.3800^,7L�a,b.�CJ 1 cI
I'olicy Nn.CL'�V-IcL(:om��ny—LS�r���� - . .. . ... �1�T l�s
I ❑ Certitied copy is hrreby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
�lc� `I0� y 5.[��/
Certified copy is filed u•ith ihe county building inspection - f3Ut�DING
a par� z c `(�,r l/ ����/� FOR APPLICANT TO FILL�N Aooaess ��3 (-��e_efi,_I
Da(r���Ap,P���ant�UL��"�" � ` ' (PiiINT OR TVPE ONLYI � � n (�
LOCALITY �'1(7_nl1�..IlN 1�'�,�
CI�:RTIFICATE OF EXE�IPT[ON FRO]1\VORKIiILS' NO. TYPE OF APP�IANCE OFi EQUIPM17ENT FEE 1�"11'"'Y`4�
C061PENSATION INSUItANCG � NEAREST }
(This section need not be completed if the work involved A�SORPTION UNIT,6TU cRoss s7. o-
O
by thc permit is for one hundred dollars (S10D) or less.) oista�cr wo. �f eHeces�o sr V
1 certity ihat in the perfnrmance of[he�eork for�vhich this AIR HANDLING UNIT,CFA4 / �j� �
permit is issutd,I shall not employ any person in any menner �Y � —
so ss in hemme su6ject to the\Cnrkers'Compenaation Lsws. BOILER,BTU �"�
/� QO APPFiOVALS ❑ATE IN�._CTOF'$SIGNnTUFE W ,
Dste Applican[ COMPRESSOR,OTU_' _f_""'� O ROLIGH a
�_• _ — Vl
NOTICL TO APPLICANT:If,aftrr making Ihis Certificatr of VENTILATION SYST[M � Z
LsemOtion, you should becnme sahject to the \Vorkerc' F-INAL �—
Cn^t �_ti•�.^. �cc�^.=!on<..f the L,h�r rnAo,yn�,�mir.t F�rih- �EVAPOftATIVE COOLER VHLIDFaTIV� �� .
���ith„Comply ��ith 5uth PrO�'�sions <ir this permit shall 6e
deemeA revnked. � FURNACE: FAU RAVITV_ � � ,
LiCLtiSEDCONTRACTORSDICCI,AR4TIOV FLOOR• 6TU—��OOn Q
I hereby atfirm thnt 1 am licen�ed undrr procisions nfChapter HEATER: SUSPENDED UNIT
9 (cammencing�vith Section 7000)nf Division 3 of ihe�usi� WALL
ness and Professions CoJe,and my licrnse is in full force snd • I 50
effect. ...���_,,..� ' �_�O - L " E _ .
License Number ��1�, ���� Lic.Class__
�ntrsctor�l V I`��(�Date �~Z�� . : . . . .
1 am exempt (rom the licensing requltements as!am a ���1 5&8 A
lirensed archilect or s registered profession�l engineer plan check fee 2540 of above. a
�acting in my prnfes5ional c3pscily (Section 7051, IIus- � {�. • •�e s 8
inesx and Frofcssions Cadc). PERMI7 ISSUING FEE$ ���_.,_
Lic.or lieg.Nn. Date TOTAI FEE �n� ,�"'�5���
HOVF,OR'?1ER-BUfLDFR DGCLAItAT10N - p�qN CHECK APPLICANT •�°•°J�O O�
1 hereby affirm thst 1 am esempt frnm-the Cnntractnr's NAM11E
License Law for the toliowing reason (Section 7071.5, I3usi- O b.J O—H J
necc�nd Professions Cbda): ADORE55 _
� �, as nwner of ihe property,��•ill do[he�a�ork and the TEL NO. --�
structure is not intended or offered�for sale (Section CITY
7044,Business and Professions Code). . \ • ^ _O C� ��
OOPJNER v \G(' � , �
1,as awner of ihz properi5'�am exclusiveiy contracting V� /� r ��
with licensed conlractors to cnnstruct the projzc[ nOORE55�����_����1�� 1 �
(SeMion 7044,Dusiness and Protessionx Code). �
CONSTiLUC7lON LLNDiNG AGCNCY CITY 2��(^ TEL.NO.
�.�
1 hereby affirm that there is a construction Iending agencY CONTFiACTOF � � � �
(or tl�e per(ormance of[he worA fnr �vhich Ihis permit is ���� _ .
issueA(Src.9097,Civ.C.). �
Lender's Nsme A�DftESS t 1�O� Pa�t-�1��
I,ender's Address CITY (��he i,,,,` TEL.NO.����_�' - .. . .
1 rer�ify iha[i have read ihis applicstinn and state that ihe STATE 7 ���� C_�7O
above informa�ion is Correc[.1 agree�o comply�s�ith all County L�CENSE NO. ��(�� CLnSS � .
urdinancrs and St�tr 1����s rcgulating HeatinF.Ventilsting and �
Air C�mditinning,and hcreUy nuthorire representati��es of[his SLG REV[RSE FOR EXPLANATORY LA'JGl1AGE � �
County to rnfer upon the nbove-mentioned properly fnr
incpe ron u pnrs.
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