HomeMy WebLinkAbout1288A \YORKLRS'C051PENSATION DF.CLARATION � 76A364C . �
1 hereby affirm that I hace a rertificate of cnnsent to self CE-918(2-80) A P P L 1 C AT 10I�! F O R P E R M IT
�nsure.orace�titicaten!\vorke�s'Compensationinsuronce,oi HEATING•VENTILATING-AIR CONDITIONING
a certified cnpy therenf(Sec.3800,I.ah.C.)
r��i��Y rro.3�6'$2 Company SCHCH Comp. Ins. Fund
� ❑ Ccrtifird cnpy is hereny furnished. � COUNTY OF LOS ANGELES BUI LDING AND SAFETY
Tract 32576 Lot 19
� Certified capy is filed with the caunty 6uitding inspectinn FOR APPLICANT TO FILL fN � sui�owc
ae{;�a�t AODRESS 1901 � Peaceful liills Roa
u��e_bL��ApD>icant Stur.mit 5heet P'.etal Co. 1PRINT OR TYPE ONIV)
LOCALITY
C1tItT11']CATE OP EXF,�fI'TIOV I'ROAf�VORKERS' NO. TYPE OF APPLIANCE OR EQUIPMEN7 FEE
CO�lP[NS.4TIQN 1NSURANCE; NEAAEST }
(This section nced not he completed if the work InVOIYed � A�SORPTION UN�T,BTU CROSS ST. �-
by the permit is foc one hunSred dnliats (SlQO)or Iess.) o�sra�crno. FRec¢sseoev , / U
1 certity that in the pednrmance nf�he���ork for which this Alfl HANDLING UNIT,CFM �` � _
prrmit is iSSued,1 sh111 119t employ any peisnn in eny manner "Lf1J Q`
— sn as to hecome subject[n Ihr tVorAers'CnmpPnsation La�4�s. E301LER,BTU y_
I AP('ROVALS DATE INSC .;TOR'S SIGNATURE l„]
Uate Applicanl COMPRESSOR,OTU �"
ROUGH fn
NOT1CIi TO APF�LICANT:If,aCter making this CertiCc;�te nf 1 VENTILATION SvSTEM ( OO FINAL -?� LL z
liremption, you should bernme .ruhject to the lVorkers' �
Cnmpensation provisiont�d the Lahor Cnde,you must forth� � VALIDATION � �
�.vifh c��+r,�s• �.�;tn sl�ch pto�•isions ur this pe�mit Shall be E`!/�POP.ATiVE C'�OIER
deemed reroked. FURNACE� FAU—GRAVITY_ ' �
LICENSEDCO:`ITRACTORSDECLARATfON FLOOR• BTU
I herehy affirm that I am licensed under pror�isians of Chspter HEATER: SUS�[NO[D VNIT
9 (rnmmencing���ith Section 7000)of Division 3 of the E3usi- WALL
w�`ss and Ymfessions Code,and my license is in fuli force and
w��ct.
�i�ense Number 195932 Lic.C�ass �43
Contrxtnr Suv�it S/M n��e 8�16�83
� 1 am ezempt (mm the licensing requirements as 1 am a
licensed architect ur a registered professional engineer Plan check fee 25",5 of above.
acting in my protession3l capadry(SecHon 705i, Dus PERM171SSUING FEE$
inessandProfessionsCode). 14 5�
�'i2��a
Lic.nr keg•No. ❑ate TOTAL FEE 16 50
HO`dG O��'YGR-DU1LDF.R 1)ECLARpTION pLAN CHECK APPUCANT -- - #• • • •8
I hcreby a[firm that 1 nm exempt from-the C�nVacfur's NAME Sumsnit Sheet t�fetal Co., Inc. �I�•�•�1 6 5 0
l.icense Law for the foilo�•ing reasun(Section 703L5, Busi-
ness sn�f'rnfec�i�ns Cnde)� ADORE55 21H11 BeI.Sllj.r2.St. �•I°.• j �1 J�c� --�
� l, as nu'ner of[he property,�eill do ihe work and Ihe CITY TEL.NO. ��
strncture i5 not intended or nfferrJ for sale (Section HacaaiianGardens 527-8863
Y044,Business and Pmtessinns C�de). - ��� 9—�3
❑ ' OWNER Ai. J. Brock h Sons, Inc.
[,as mm�er of the pr�perty,am exclusively contrxting
vifh licenxed conttactnrs [n tonstruCt [he prnject MA�� � 1698 Greenbr3ar Lane, i�22�F
(Section 7044„Businr55 and Pro(ecsions CoAn). , ADDRESS
CONSTRUCTION L1:NUING AGENCY CITY �$reg TE�.No. 529-8170
1 herebyraffrm that there is a construction lendin�agency � CONTRACTOR Su�it Sheet Pietal Co. I11C � � - � - � � �
for the erformance of the work for�rhich this ermlt is � � -
issucd�Sec.3091,Civ.C.}. . ... _ . � . .
LrndersName . ADDRESS 21811 Belshire St.
LendePs Addrcss � CITY Haiaaiian Gardens rEt.No. 527—g$63 � � � � �
1 certify that I have read this applicaiion and state th�t the STATE � LIC. �
aboce informsii�>n is correct.t agree to eninpty���ith all County LICENSE 1J0. 19Sg3�L CLA55 C-43 -
ordinancex anA State la�vs regulsting Hen�ing,Ventilating and -
Air Condi[ioning,and 4ere y authorize representati.'es of lhis SEE REVF.RSIi�OR EXI"LANATORY CAVGUAGF, � �
County to encer upon ie above�mentioned propeny for
ii specfion purposes. . . . ' . - '
' 8/16/83
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