HomeMy WebLinkAbout1587A (9) \t'ORKERS'Cn\1I9iNSATfONDL'CLARA710N 76A364C �
1 hereby affirm iha[ 1 hare s certiC�cate of consent to self CE-87Q 12�II0) �+P P L IC AT I O�! FO P. P E R M IT �
incure,or a cer�ifica[e of�Vorkers'Cnmpensation Insurance,rir HEATING-V ENTILATINGAIR CONDITIdN1MG
a certified rycop�(y�(t.hereof(Sec.7800,Lsb.C.)..�r� .
PnlicvNorS`2��C�mpanY��✓�� ' " ' Vh1k y�5 � .
� Certified cnpy is heroby furnisl�rd. . COUNTY OF LOS A?JGELES BUIL�ING AND SAFETY
P I�..� 00 �{�-
CrrtiTied copy is fiied«�ith the rnunty building inspection � �j�
de artmrnt �f/�/� �OR APPUCANT TO FI LL fN aui�oirvc I�a' ('1,_e_(�,t k..�l,�S 1�U_
�/� (PRINT OR TYPE ONLY} ADDRE55 1 CLj �:U
I)atr�_2�pPPlicant_}Jf�S.J• _
. [�f LOCALITY �i�YY���d ����
CEiRTll�ICATE OP HXIi!11PTfON FI205715'ORI:FRS' NO. TVPE OF APPLIANCE OP EDUIPMENT FEE 1��
C011PCNS.qT10"I INSURATCI: NEAREST �.
(This section need not be completed if tl�e �vork involved ABSOFiPTION UNIT.OTU enoss 57. � a
by lhe permit is for one hundred dnllars (5100)or IrSsJ �ISTRICTN0. PPOCE:'�09v V
1 cer�ify[hat in the perfmmance nf Ihe�vork for�ahich this AIFl HANDLING UN17,CFM �
permit is issued,I shail no[empioy any person in any manner O -
sn as to become subject to the 11'orkers'Cnmpensation L�ws. �011Efi,6TU �
1 n � APPROVALS D�1TE iN= [CTOR'ssiGNn7uRE
Date Applicant I COM11PRESSOR,BTU�D�OC� �V pOUGH W
_ � N
NOTICE TO AYPCIC:\NT:If,after makin,v,this Certificate nf VENTILA710N SYSTEM FINAL � �'(� �Z
Esemption, you should brtome�subject to Ihe 1Vorkers'
Comprnsatinn provicions of ihe Labor Code,you must forth- EVPPORarIVE COOLER VALIDATIO� �
�e-ith cpmply wilh Such prna•ic(nnc or tl,is perrt:if cha11 ba
dCemPd fevoked. FUFNACE: FAU _ �,�2 VI LY
LICiiNSCDCOVTRACTORSDECLAItATION FLOORr e�J_XO�ALi, �D� .
1 herehy affirm that 1 am licensed�nder pfovisions of Chaptrr � HEATER: SUSPENOED UNI7
9(commencing�vith Sec[ion 7000)of Division 3 nf Ihe 13usi- WALL .
ness and Nrofessionx Code,and my�license is in full fnrte and �j ���/� C � � 'S
�ect. �7(�� ' J ILI�+ �
1i\^nce Numher�.]_i?�� Lic.Class��a � -
�� n� `,'
Cnntractnr�l-I�e"���Date��Z��_ .
� 1 am exempt from the licensing requirements ai 1 am a
� licensed areh@ect nr a teg�stered pmfcssion�l rngineet Plan cheek fee 25°b Of abOVC. �
acfing in my professional capacity (Section 7051, Bus- - » � -q�} rJ�{�]p
iness and Professions Code). PERMIT ISSUING FEE S
�.3 � �...'. . .g
Lic.ur Re�,Vn. Date TOTAL FEE
IIO�iF.O\1'NER-13UILDER DFCI,A1tA7ION pLAN CHECK APPLICANT � • •5 a 2 5
1 hereby a(firm Ihat I am esemp[ trom�thc Contractor'S NAME • •:l,�i.G J�
License Law for�he followinR resson (SeCtion 7031.5,IIusi- '
ness and Professions Cnde): AD�RESS
oS30—F33 -�
� I, as owner of the property,�vill dn the«�ork and [he ,
strudure is nnt intendeJ or offeced for sale (Section CITY TEL NO.
7044,[3usinrs5 and Nrofessinns Code). •
� i,as��v�e��r�ne OWNER ���CO C« `• Su�S
property,am esch�sively contracting
���ith licensed enntractors to construct the project MAIL� /a(�, ���`„(.�1,�. '���7t
(Section 7044,Businese and Professions Code). ADDRFSS }_�(^lb_C`f_� KJI �•
CONSTRUCTION LENDWG AGENCY CITV '2�e_ TEL.NO.
I hrreby affirm [ha[ fherc is a construction lenJing agency V y�.
fur (he perform3nce f ihe �vorA for��'I�ich this prtmi[ is CONTRACTOR`=N'�n,� oS�� • r1 � .
issued(Src.3097,Civ.C.). �' �
Lender'sName ADDR[SS �ti3o � . P�ei�fieo - - � -
Lrnder's Address �:✓�_ ,���;�^ /�� -
CITY r'yl 7EL NO.�D
I cettify that 1 hare read this spplication and state[hat the �TATE LIC. .f1
a6ove informstion is correc[.f agree to comply�vith alI County UCENS�._�NO. ��5� CLA55 ���-V � . .
ordinances and S�a�r laws regulating Hea�ing,Ventilating and .
Air Conditinning,and herebq authorize representatirrs af this SEE RF.VGRSI FOR EXPI.ANATORY I,ANGUAGH . . ,
Cnunty ta entrr upon Ihe :+boee-mentioned property for ,
inspection p��tposes. � �
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