HomeMy WebLinkAbout1585A �coxxLtes co��rrys.qnoy nec�,�a,�r�oN 76"'�4O A P P L IC AT I O I�! FO R P E P P!i IT
l hereM1y affirm that I hare a'certi(icate of consent to self CE-810(2-801 ♦ �
insure,oracertificsteol�vnrkers'Compensstionlnsurance,oi HEATING-VENTILATING-AIR CONDITIONING
s certified c(oyp�yr_th/erenf(Sec.3800,I.ab.C.) q
PnlicY Nn.L�'YYJ�Compan)'ZQY�1�� � �r^� �'��/(�
� ❑ Certitied copy is hereby nirnished. - •''. /? COUNTY OF LOS A'�GELES � BUIL�IPIG AND SAFETY
�—i/Certifiedrn ' � ~ �O� ��—�
1� �y rs tiled«-ith the rn�mty/n�ii�ldin�inspection FOR APPLICANT TO FILL IN out�o�r�c,
"'� d�men�_�rr�icant���'C..(�'J�r�`�`�\ (PRINT OR TYPE ONLY) ADDRESS I q 15�eae�-�vl I-�i Ils �
H IOCALITY 1 (��, �
CI;RTIFICATl OI'EXE�IPTION FROA1�i'oa�;i:as' NO. TYPE OF APPLIANCE OR EQUIPM11ENT FEE �`���Lf_y��1
COSIPG?CS'ATION7N5UR.4NCE -� NEAREST }
(ThiS SCMion nCed not bC completPd if the u•ork involved A�SORPTION UNIT,BTU CROSS ST. O
hy the pecmit is for one hundred dollars (SIDO) or lessJ DISTRICTNO. � vaoce_�eoev � V
I certify that in the perfnrm�nce of the�vork for w�hich this AIR HANOLING UNIT,CPPd a
permit is issued,I shalt nnt rmploy any person in any manner Q _
so as to become subject to the 1Varkezs'Compcnsatian Laws. BOILER,BTU U
. � � MPFiOVALS DATE iN,�Ecro�'SSiGNaruRE
W
Date Applicant COMPR[SSOR,6TU -� _ qOUGH �/>� d� N
NOTICIi TO AYPLICANT:]f,after m�king Ihis Certificate of VENTILATION SYSTEM FINAL t�` � Z
Exemption, ynu should betome subject to the 1Vnrkers' ���` �—
ComDensstion provisions of the Labor Code,yau must fnrth- �
�vitli cnmply �vith Such Pro�'islons or [his permit xhali he EVAPORATIVe CGOLEn VALIDATIOiJ
dremed revoked. � � FURNACE: FAU C�AVITY �h 00 �
I.ICtiNSF,DCONTRACTORSDECLARATION , FLOOR� 6TU_��O'ah V - � �
1 hetefiy afflrm that 1 nm licensed under provisions of Chapter HEATER: SUSPENDED UNIT I
9 (cnmmencing�vith Section 7000)of Division 3 of the Ausi- WALL
nrss and Professions Cnde,anA my license ir in fuil force and 1� "� - � I�� -�s
t r
L�c�n��Vumher�_IS��. Lic.Ciass`'�� e
Co�torr�7--1V)�\��`-1��I7ate�—�Y-� . . . �
- � I am ezempt frdm the licensing requirements as 1 am a �'�-,� J 8,S A
lirensed architect ur a registerrd profrsvonal enginecr P�an cheCk fee 25'0 of above. ��• • •�• •8
scting In my profession�l capacity (Section 7051, Dus- � p :�{•-•5 3 2 5
iness sne��mtescions Ct�de). PERMIT ISSUING FEE S
Lic.or iie¢.No. Uare TOTAL FEE i� u • • •J J i�j�
� I{OStf O\VNGR-flUILI)ER D1iCLARATIOM PLAN CHECK APPLICANT � O A�J O—H�J
.1
�`hereby aftirm th�t I am exempt from-[he Cnn(ractor's NA1dE �
cense Law for the tollowing reason (Sedion 703L5, i3usi- - �
,�and Nrofessinns Code): � ADOftE55 - �
�t�I, as owner of the property,�vill do the work and the CITY TEL.NO. -� �
ktructure is not intrnJeJ or offered for sale (Section
To4a.Dusiness and Pro(essinns Codc). �-^ � � .
OWNER {Y1
i�,as owner of the properry,am exdusively coniracting
�"����th IicenseS mntrsc[ors to construct the projrct MAIL
(Sec[ion 70A4,Duziness snd Professions Code). ADORESS l�a���_C��,nh��tir #�Z�
� • CONSTRUCTION LIiNI11NG ACfiNCY CITY �J�pR TE�.NO. -
� V'�
f herzby afCrm that there is a cnnstruction Iending sgency � ��a����
tnr !he perfotmsnce ot ihe �vork (or i��hich this prrmit is CONTFACTOF ��
issued(Sec.3097,Civ.CJ. C `/�
Lender'sName ADDRE55 1130 G- lY�fiea
Lender's Address CITV ��,he; Y,,, TEL.NO./. a"71fJ . .
ip3`�- �
[ certity ihat I hao�e read this aV0lication and 5[ate ihst the � STATE ^��j UC.
abo��e infonn�tion is correct.[agree to compl��with ali County L�CENSE NO. � C.p-L� C�ASS ��O . _ .
ordinances and State I�o�s reguluting Hrn[ing,Ventilriing and �
Air Conditioning,and herzhy authoriee representatives of this S£,E REVERSE POR P.XPLANATORY I,ANGIJAGi; .
County to enter upon the aboce-mentioned properly for
�ins ec�ion purposes.
QQ-�.h.e�,w� �-Z�-l��3 ,
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