HomeMy WebLinkAbout1586A NORKGRS'CO�IPLNSATION Di:CLARATION - 76q�64� A P 1 L IC�T I O�� FO 1'C P�fY M� I �
I htreby affirm that I have a•certiCcate nf consent to self CE-818(2-801
nsure,oracertificsteoiNnrker.s'Compensationlnsursnce,oi HEATING-VENTILATING-AIFZ CONDITIONING
i certifed(cyo7py there�/of(Sea 3800,Lab.C.1 ,1
�olicY Nn.l'�=��(6 Comp3nY��'�.�-f " ' V��� L��D5
� ccrt�ned rnpy is hereny�urnis��ee. COUNTY OF LOS ANGELES BUILDING AND SAFE7Y
C'1 Ob `(50,Y
-/y�,�c.er�ified capy is filed with[he countp building inspec[inn FOR APPLICANT TO FI LL IN RUILDitaG u
� d ir n (� �^11,�1�11^� �/� � ADDRESS `q�� �Q�I_I 1�1�_�
)ate����1pp����nt_N0_�l�L.�.Y�`+•W`!\_ . (PRINT OR TYPE ONLY)
LOCAL�TY (���
ClRTIPICATE OF[XLNPTION FR0�1\1'pRKI4R5' NO. TVPE OF APPLIANC[OR EQUIPh1ENT PEE J�'l�Y-`
COAINLNSATION fNSUR.ANCG � NEAREST . , }
T�11S SPC�1Otl neec� nn[ he COIiI(1�Cfed I((�1C \CO[�C InvO�VPd ABSORPTION UNIT,BTU CROSS ST. O
�y the permit is for one hundred doi�ars(S100)or iess.) oisrAicra�o. Pnoce seoev V
cer[ify that in �he prrformancr of the�rork(or�chich Ihis A�R HANOLING UNIT,CFA1 � �j �
1•rmi[is issued,I shali not em In an � -
p y y permn in any manner �L �
n t��become subject to the 14'nrkers'Compensation Lswe. 601LER,6TU V
(�r� f� � APPROVALS DATE 1' :ECTOF'SSIGNATU�E W
ite Applicant- - � COMPRESSOR,BTU_�ulvV�' �V ROVGH P-i _�� �
�TICii TO APPLIGINT:I(,aRer making this Certificate of VENTILA710N SYSTEM� �� �/>-�. Z
m�tion, you should he[nme subject to the \\'orkc�s' FINAL ��_�v.3 �� �-
nprnsafion pro��isinnt of ihe Lahor Code,you must(nrth� -
�, �v:,�oF%.nve C06LE: VALIDATION
�i �umply �vi�h sucn provisinnc <�r this permit shall be
'ned revnY.ed. FURNACE: FAU GRAVITY �O �� '
} I.1CF;N5h:DCONTRACTORSDGCLARATION F���A' ATU-��IC��
�rehy affirm that 1 am licensed under provis{�ns n(Chop[er H[ATER: SUSPENDED UNIT - . �
�rnmmencing�rith Sec�io�7000)of[]ivisinn 3 of the Pusi� WALL
ns and Profecsions Cnde,anA my license is in full(orce and �� i�� � � � Sp .
�fPcL 11 �h ,
�cense` ��er3`�5z�y Lic.Cl�ss�'r`-' . �
)niract�r � e �'� Datc�-(��
� 1 am exempt fmm ihe licensing requirements a5[am a �� Jr 8�6�
licensed arehitect or a registcred prnfessionsi engineer Plan CheCk fee 2Ei45 of above. �
xtin; irt my protrtsional coPacitY (Srction 7051. Ilus- SD �{�• •�•�• •a
, inesc and Profescions Code). PERMIT ISSUING FEE$ '�� ^I.•'•5�0 O
� o
�c,or Res�No. � Date TOTAL FEE • •-^J��O O�
� IIOt��O1t'VP:IL-I3UILDFR pF.CLARATION pLAN CHECK APPUCANT -
�hereby affirm that ! nm exempt from�Ihe Contractor'.s NAM11E 0�£?3 0�-8 3
cense Law fut Ihe (ollowinK reason (Section 7031.5, flusi�
�ess and Prntessinns Cnde): ADORESS
[f.-�� I,as o�vner-of ihe pro�crty,�vill dn!he���ork nd �he TEL.NO. � -�
{� structure is not intended or otfered for sale (Seetion CITY �
� 7041,Business and Professions Code). �� �J �.
06VNER —��`O�1}�.�_S_
1,as owntr nf the propertl'.�m esclusively contracting
with Iicensed contractors to con<truct the Froject MAII �i /1�y /�',,,�/�ep�(��`� ,���/)—
(Sectiun70JA,[lusinessandProfrssionsCode), AOORESS �"1�� `t ��� l _1
CITV p�. TEL.NO.
CONSTRUCTIDN LLNDING AG1iNCY �-��+ �
ereb}• affirm that Ihrre is a tons�ruction lending agency ,1�, .
�[he performance uf the work (or �rhich [hit permit is CONTRACTOR�`AG�� {-{1e;� , � � � �� � �
vrJ(Sec.3097.Civ.C.). - L14 . . •fJ
7der'sNsme AOORE55j13o £. --�",�C'��.�-��1Q
.ender'sAddress CITV {�y��y�,p� TEL.NO.��-a�l� . . .
1 1�� �1L.1_.
Certify that I have read ihis application snd 5taie tl�st�the STATE r� UC. �
b���e inlorm�[inn is corrcct.I sFree I��cnm�+ly�a�i�h al1 County LICENSF.Nn.�-!S��y_ CLASS_�_� . . ..
�rdinancrs and State Is�vs rcP.������ng Nca�in¢,Ventilating and
1ir Conditioning,�nd hereby authurize representatives o(this StiG RIiVGIiSE£OR EXPLANATORY LANGUAGIi .
7ounty tn enter upon Ihe sbove-mentiuned property fnr
�svecri� �urr s•c�
—� �-L'-��
'�i¢natur^�fl'rrmitt e Date . . . .
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