HomeMy WebLinkAbout1288A (6) \VORKLRS'COCiPENSATION DF.CLARATION � 76A364C . �
1 hereby affirm that I hace a rertificatc of cnnsent to self CE-918(2-80) APPLICATIOh! FOR PERMIT
insure.orace�tificaten!\vorke�s'Compensationlnsuronce,oi HEATING•VENTILATING-AIR CONDITIONING
a certified cnpy therenf(Sec.3800,I.ah.C.)
r��i��Y rro.3�6'$2 Company SCaCC Comp. Ins. Fund
� ❑ Ccrtifird cnpy is hereny furnished. � COUNTY OF LOS ANGELES BUI LDING AND SAFETY
Tract 32576 Lot 19
� Certified capy is filed with the caunty 6uitding inspectinn FOR APPLICANT TO FILL fN � sui�owc
ae{;�a�t AODRESS 1901 � Peaceful liills Roa
p��e_bL��ApD>icant Slur.mit 5heet P".etal Co. 1PRINT OR TYPE ONIV)
LOCALITY
C1tItT11']CATE OP EXF,�fI'TIOV PROAf�VORKERS' NO. TYPE OF APPLIANCE OR EQUIPMEN7 FEE
C01tP[NS.4TIQN 1NSURA\CE; NEAAEST }
(This 5ectinn nced not he complCted if the R'Otk InVOIYed � A�SORPTION UN�T,6TU CROSS ST. �-
b}' the pertnit is foc one hunSred dnliats (SlQO) or less.) �15TR�CT�O. �RCCESSEDE`/ , / U
1 certity th.�t in the pednrmance nf�he���ork for which this Alfi HANDLING UNIT.CFM �` � _
prrmit is iSSued,1 sh111 Ont employ any peisnn in 3ny manner �F��J 0
— sn as to hecome subject[n Ihr tVorAers'Cnmpensation La�vs. E301LER,B7U ��tpVALS DA7E in�sr crna�s swanruae �
Ltl
Uate Applicanl COMPRESSOR,OTU �"
ROUGH fn
NOT1CIi TO APF�LICANT:If,aCter making this CectiCcste nf 1 VENTILATION SVSTEM ( QQ FINAL -?� �L z
liremption, you should bernme .ruhject to the lVorkers' �
Cnmpensation vrovisions of the Lahor Cnde,you must forth� � VALIDAjION � �
�.vifh c��+r,�s• �.�;tn sl�ch pto�•isions or this pe�mit Shall be E`!/�POP.ATiVE C`�OIEA
deemed reroked. FURNACE� FAU—GRAVITY_ ' �
LICENSGDCO:`ITRACTORSDECLARATfON FLOOR• BTU
I herchy affirm that I am licensed under pror�isians of Chspter HEATER: SUS�[NO[D VNIT
9 (rnmmencing���ith Section 7000)of Division 3 of the E3usi- WALL
�y`ss and Ymfessions Code,and my license is in fuli fnrce and
w��ct.
Li�ense Number 19593_2 Lic.C�ass �43
Contrxtnr Suv�it S/M n��e 8�16�83
� 1 am exempt (mm the licensing requirements as f am a
licensed architect ur a registered professional engineer Plan check fee 25",5 of 06ovC.
acting In my protession3l capacity(Seclion 705i, Dus- PERM171SSUING FEE$
inessandPmfessionsCode). 14 5�
�'i2t��a
Lic.nr ReR•No. ❑ste TOTAL FEE 16 50
HO`dG 0�4YGR-6U3LDF.R I)ECLARpTION pLAN CNECK APPUCANT -- - #• • • •8
1 hcreby a[firm that 1 nm exempt trorn-the CortVactur'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'rnfes�i�ns Cnde)� ADORE55 21H11 Be�.Sllj.r2.St. �•I°.• j �1 J�c� --�
� l, as nu'ner of[he property,�eill do ihe work and Ihe CITY TEI.NO. ��
structure i5 not intended or nffered for sale (Section HacaaiianGardens 527-8863
7044,Business and Pmtessions C�de). - �&1 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(escions COdn). , ADDRESS
CONSTRUCTION L1:NUING AGENCY CITY �$reg TE�.No. 529-8170
1 herebyraffrm that there is a constructian IenJin�agency � CONTRACTOR Su�it Sheet Pietal Co. I11C � - � - � � �
for the erformance of the work for�vhich this ermlt is � � -
issucd�Sec.3097,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. �
abo��e informsii�n ic correct.t apree to coinpty���ith all County LiCENSE NO. Z�JSg3Z CLA55 C-43 -
ordinancex anA State la�vs regulsting Hen�ing,Ventileting and -
Air Canditioning,and 4ere y authorize representati.'es of lhis SEE 0.EVF.FiSIi�OR EXPLANATORY LAVGUAGF, � �
County to encer upon ie above�mentioned propeny for
ii specfion purposes. . . . ' . - '
' 8/16/83
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