HomeMy WebLinkAbout1823A \VOKKI;RS'CORiPP.NSATtON I)I?CLAItAT10N ' 76A364C A P P L IC AT I O l�l FO R P E R iilli IT �
1 hereby aCfirm [ha[ I have a'certificate of coneent m se�t CE-91£3(2�BD1 �
insure,oracertificateo(15'orkers'Compznsationlnsurance,ni HEATING-VENTILATING-AIR CONDITIONING
a certified cnpy thercof(Sec.J800,Lab.C.) �!1 �) �
1'olicY NiWP�.L��ompsnY—E�(��NT ,y.}� �x�q
Xr � COUNTY OF LOS ANGELES
� C Certified cnpy is herehy Nrnished. (3UILDING AND SAFETY
� Certified copy is filed wi�h the county building inspectinn
depnrtmen.t. FOR APPLICANT TO FILL IN BUILDING
Da[e 9-24=81-r\pplicant F�'10NT (PRINT OR TVPE ONLY) A�ORESS 068=PEACEF'UL-HIIS,S-RO
CGRTiFICATit OP EXE�IPTIUN�RO�t R'ORfiERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
LOCALI7V DIAMOND BAR �
COh7PLNSATIO?I INSIIRANCG � � NEAREST�T 29 PLAN 2 T �'
caosssr. , , RACT 35741 a
(This section need not 6e completeJ if the a�ork involved ' A�SORPTION UNIT,BTU �
by the permi[ is for one hundred Jolfars (SIOD)uc IessJ o�s.R�crr�o. aaocess=oev V
1 cer�ify that in the perfnrmance of the�i�ork for a�hich[his � AIR HANDLING UNIT,CFM qp �
_ ermit is issued,I shali not em I> n y � � �� /h y�� O
p p�}':� y prrsnn in an manner
so as In Aecome subject tn the 1V�rkers'Cnmpensatinn La�vs. . BOILER,8TU �... —
� APPROVALS �ATE INSGECTOR"SSIGNATURE („)
W
Date Applitant COMPRESSOR,BTU�'A$�QQQ- I ROUGH a
' / y .
NOTICF,TO APPLICANT:If,aCter making this Certificste of VENTILATION SYSTEM FINAI � Z
Esemption, you should become subject in ihe Workers' —
C��mpensstion pravisions bf the Labor Code,you must farth- �
�vith comply with such provisioni or this permit shatl be =V:.FO.^.:.TtvE COCLHR I V��.��r�1T��i'i� �
deemedrevoAed. FURNACE: FAU_GRAVITY_
LICF.NSLD CONTRACTORS DF.CLARATION � FL.00R: 8TU �
1 hereby afFirm that f am Iicensed under provisinns of Chapter' HEATER: SVSPEND[O UNIT
9 (enmmencing wilh Section 7000)of Division 3 of the fiusi• WALL
ness and Professinns Code,and my Iicense is in full force and
cftect.
License Numher 158688 Lia Class C-20
� Contractnr_KINN$_X_A� pate 9-24=81 -
� � I am ezempt from the licensing reyuirements as I am a! �
- licensed srchitect or a registered prnfessional engineer� p�an check fee 25°o Of abOVE. --
`�tlin� in my professional caFacity (Srctiun 705t, Bus-' �� �2,3 p
iness and Professions Cnde). � PERMIT ISSUING FEE S 8
Lia or�trR.No. Date TOTAL FEE 23 $� �'��� � � ��
Ii011£01VNER-BUILDF.R DLCLAfLAT[ON � ��'�°2 3:5 0
PLAN CHECK APPLICANT �
I hereby affirm that ] am exempt trom-the Contracror's�. NAMe . ��,�.�2`'s Q�' -
License Law for[he fnilo•ving rexson (Seclion 7071.5, �usi-� ;,.��1 `81
ness and Professions Codt): AD�RESS -
� 1, �s naner of fhe proputy,�rill do[he trork and the _ CITY TEL.NO.
svucture is nnt intentled or offered for sale (Section
7044,pusiness and Professio�s Code).
D , OWNEfi . �
� 1,as n�vner of the pmperty,am ezclusively contracting' M.J. BROC7KS AN� SONS
n•ith licensed contractars ro construR thc project. MAIL
($ection 7044,Dusiness snd Profrssion.c C��de). ADDFSE55 �8_GRFF.NT3RTAR T.Aj�',_�_#22
CITV $jjEjj � jZ(Z],TEL NO.
CONSTI2UCTION LLNUINC ACGNCY � �
1 herebl' a(firm ihat there is a construc[ion Itnding agency�
for the performance of ihe�vork fnr �ehich ihis permit is� CONTRACTOR HI�EY AIR CONDITIONING --
issued(Sec.3097,Civ.CJ. � - �
Lender'sName I aoo�tess ' 4LS._ANAHEIM_BL�.
Lender'sAddress pNAHEIM� CA 772-1441
� CITV � 7EL.NO. �
I ccrtify that f ha�•e read this appiicstion anJ stste thut ihe STATE � LIC. �
� aboee inform�tion is correct.f agree tn comply�rith all Coimty� LICENSE NO. ISB6HS � CLASS (]-20
ordinances and State la«s rcguluting Neating,Ventilating and� � �
Air Conditioninc,and here6y authorize representa'ves of�his� SI:G RtiVERST POIi EXPLANATORY LANGUAGE
Coiroty lo enter r�on Ihe ahove-mentlaned r upett for�� . � � �
'is ec �n purpn.rs /} �/
..�
Signature af Permittee D�te
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