HomeMy WebLinkAbout1286A NORK@RS'CO�IPENSATION DECLARATION � 76A364C �
1 hereby affirm that 1 ha��e a'cenificate of consent to self �E.8,8�2.so, � .A PP L ICAT i O N FO R P E R�11 I i
insure.oracertificateo(R'nrkers'Cnmpensationlnsurance,or HEATING-VENTILATING-AIR CONDITIONING
a carfified copy thereof(Sec.3800,Lab.C.)
r��r�YN�.3IIfi�flZc�mP��y�tat�Comn_ Tns.—Fund
� ❑ Certitied w�py is hercby turnished, COUNTY OF LOS ANGELES BUILDING ANU SAFETY
Tract 32576 Lot 1
��Cer�ified rnpy is filed with Ihe county huilding inspection
,g J FOR APPLICANT TO FILL IN aui�owc 1915 Peaceful Hills Road
dt3r1� Slll'Illlj.t Sheet Metal (PRINT OR TVPE ONLV) nDDRESS
Uate Applicont
CIRTIFICATL OP EXESIPTION FRO�f 14pRKF.2S' � NO. TYPE OF APPLIANCE OR EQUIPMEN7 FEE
LOCALITY
CO?7PENSATION INSURATCE� NEAREST � }
(2�hi5 SeC�iOn rteed not hf cOmpiCted i( thC wOtk in�'OlVed A850RPTION UNIT,t3TU CROSS ST. O
by the permit is for one hundred dollars (5100)or (essJ pISTRICTND. PROCESSEDOY V
1 certify ihat in the performance of the wnrA fnr wLich this AIR HANDLING UNIT,CFM �
permit is issued,1 shall nnt empiny any person In any manner �
so as to become subject ro the lVorkers'Compens3tion La���s. BOILER,BTU F—
APPROVALS DATE i' .+ecrOn'SSiGNATUAE C.1
Date Applicant COMPRESSOR,BTU ROUGN � a
�i�- N
NOTiCE TO AI'I'LICANT:If,9fter making�his(;ertifcate�f ' 1 VENTILATION SVSTEM 6 Q FINAL � � � G� Z
lixemption, you shuuld become subjec[ tn the lYnrkers' �—
I ('nmpencatinn prnriainn<nf the I,ahnr Code,you mi�<t fnrth- EVAPORATIVE COOLER
�vith comply vvith such provisions or this permit shall be VALIDATION
� deemed remked. FURNACE: FAU—GRAVITY
LICLNSLDCOPITRACTO[2SDLCLARAT104 FLOOR� 6TU
� I herehy affirm thst 1 am Iicensed under procisions nf Chapter . HEATER: SUSPENDEO UNIT , . . .
- 9 (rnmmencing with Sectlon 7on0)o(pivi�inn.l of the�usi� WALL
ness and Professions Code,and my license is in full fnrce�nd
eftec[.
��se i�rumber 195932 i.ia C�ass C-43
CS.�ctor�lLP,R!i�s ri Date�16L3 c, '1G Q(�{�
� I am exempt from the Iicensing requirements as 1 am a
licensed architect or a registered professiunal rngineer plan eheck fee 25°6 of above. +�..'. • • •8
acting in my profrssionai capaCily (Sec(iun 7051, [3us�
inessandProfessionsCode). PERh71TISSUINGFEES lO $0 �� ���.� ��Q
Lic.or Rcg.Nn. Dste TOTAL FEE - 16 •�o�•�� (j 5 fl�
f10UG 06'NI;R•IIUILUIR➢T{CLAR,aTION pLAN CHECK APPLICANT �
1 herehy ,rr+�m �n�i � am �z�m�s frnm�the Con[ractnr's NAME S��t Sheet Pietal Co_,_Inc. 0 fl 1 9—II 3
� Licenee Law for Ihe follnwinR rcason(Sec�inn 7031.5, [3usi- -- .
- ness and Profeszions Code): ADDRESS 21$11 Belshire $t. .+
� 1, as mvncr of the property,wiil do the work and the
J
I s t r u c t u re i s n o t i n t e n d e d o r o f k r r d f o r s a l e (S e c tin n � ��T Y H a w a i i a n G a r d e n s T E L.N O. S Z J�H H G 3 �
7044,Rusiness and Pmfessions C��de).
� I,as o�vner of the property,sm esclusively contracting OWNER p(. J. Rroek & Sons IItC.
Iwi[h licensed controctors to construct the project MAIL �
I (Section 7044,[]usiness and Professions Code). ADORESS 1698 Greenbriar Lane !1224
CONSTI2UCTIOV LI>NOING ACLNCY CITY Brea TEL.NO. SL9—SI]O
1 hereby affirm that Ihere is a consiruction Icnding agency �
fnr the performance nf Ihe work (or which this permit is CONTRACTOR $lltDlit�t Sheet Metal Co.�11C. � � �
issued(Se[.J097,Civ,C.). -
I,ender's Name � AooRE55 21811 Belshire St. - -
Lender's AdJresi CITY HawaiianGardens 7EL.NO.SZ7—HHG3 _ � - -
I cer[ify that 1 have rend[his�rr��������n and state that the
abo�•e infarmation is correct.[agree ro comply with ail County LICENSE NO. 19S93Z CLASS C�3
ordinances and State la�as regulating I{eating,Ventilsting and ,
Ait Conditianing,anA hereb5'author'e representatices of this $GE REVIRSE GOR F.XPLANpTORY LAVGUAG6
County to enter upon [he above- �•ntioned property for � -
in �ection piirposes. . _ . .
8/16/83
.ig ture nf I'er itee Date
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