HomeMy WebLinkAbout1824A �t'ORKLRS'CODik'TNSATfON DECLAR.4TION . 76A364C A PP L IG AT 1 O N FQ R P E R fN�(T �
1 hrrehy affrrri that 1 have a'certificate of consent tn selt CE�H18(2901
insure,or a certi(icate nf Workers'Compensatinn fnsurnnce,oi HEAT�NG-VENTILATING-AIR CONDITIONING
a certi(ied copy thereof(Sec.3R00,I,ab.C.) �� ����
r��icv'���1P817142�„mp�ny Fremont
I ❑ Certifird copy is hereby tumished, COUNTY OF LOS ANGELES BUILDING AND SAFETY
n Certified Copy is filed with the county huiiding inspection 6UILOING
department. FOR APPLICANT TO FILL IN qoortess 2074 PEACEF[TI. HILLS ROAD
Uate 9-24—$lApplicant_j{Ij�J11Rv n(�` (PRINT OR TYPE ONL,Y) _
CERTIFICATE 01'EXE9IPTION FR0511VORKERS'
� NO. TYPE OF APPLIANCE OR EQUIPMENT FEE �ocaurv LOT 3Q_EZ�1N_4SRACZ3574
CO)1PGNSATION fNSURANCfi NEAREST
(Thit section need not bC completed if th0 ts•OIk inYolvPd � A6SORPTION UNIT,BTU cr�oss sr. DIAMOND BAR a
by the permit is for one hundred dollars (5100)or less.) rns.aicrn�o. eaocesseoev �
U
I certity that in the performance of the�rork For which IhiS� AIFi HANDLING UNIT.CFM � M���
I �
— permit ic istued,I shall not employ�ny person in any manner �
so as to become subjeCt to the�4'qrkers'Compensatii�n Laws. BOILER,BTV F.. —
. APPROVALS DATE I'rSCECTOR'SSIGNATUPE U
W
nate Applicsnt � 1 � COMPRESSOR,BTU 60�000 � ]_S.00 �OUGH a'
�
NOTICE TO AYPLICANT:If,aftrr making ihis Certificate ot VEN7ILATION SVSTEM � lC �/�n Z
F.<emption, you shauld beCome sUbjecT ro the 11'mkers' � FtNAL V 1(LVa< —
Cnmpensstion prm�isions nf the Lahor CoJe,you must forth�
w'ith comply wi�h such provisions or ihis permit shall be EVAPORATWE COOLER VaL DAT(Oi4
deemedrevoked. FURNACE: FAU_GRAVITY
LICIiN$IiDCONTRACTORSDIiCLARATION PLOOR� eTU
I herehy affirm that 1 am licensedunderprovisionso(Chapter HEATER: SUSPENDED UNIT
9 (commencing with Sectian 7000)nt Divisinn 1 nf[he Dusi� WALL
ness and Yrofessions Code,and my license is in fuil force and
effec�,
License Numher_1_5$6_88_ Lic.Class C=20
Contr�ctor_j(I[J[�`}(_,g(^ 6ate_J�24-81
� 1 am exempt from the licensing requirements as I am a ,
—� Iicensed architect or a res�scered protessional en¢ineer Plan theck fee 25°0 of above. —
acting in my profession�l capacity (Section ^051, llus-
iness and Professinns Code). PERMIT ISSUING FEE$ 8,�
' Lic.or ReF.No. nate TOTAL FEE Z3 .
� H0:.1E O1VNIiR-13UILDP.R DL•CLARATION ' P�AN CHECK APPLICANT
' I hereby nf(irm ihaf 1 am esempi fmm-ihe Con[ractork NAME � . �� �2�1�
� License Law fnr[he fNinwing rtason (Section 703L5,Dusi•, . �e � ♦� .,
ness and Prnfessinns Code): ADDRESS 'I��•2�j Jr Q
� 1, as a�vner nt the property,�rill do the�vork and the � , � _
� structure is nnt intended or otfzred for sale (Sectian . CITv TEL NO. •+�':°z J 5 Q c;
7044,Rusiness and Pmfessinns Code). i�n n� i 8�
❑ OWNER
1,as mvner of the prnperty,am exdusively cnniracting j+j..T_ RRD(,`j�$�$pjQ$
with licensed mntractors tn construct ihe pmject MAIL 698 GF2EENBRIAR LANE #224
(Section 7044,pusiness and Professions Code). ADDRESS�-
CITV TEL.NO.
CONSTRUCTION LIiNUWG AGIiNCY � BREA� CA 92621 �
1 hereby affirm thut [here is a construcfion tending agency �' --"� - .
(ar the performance of[he �cotk tar w�hich �his permit is- CONTRACTOR j�C�NDIT2�NIN
issueq(Sec.3097,Civ.C,).
I.ender's N�me ADoness 1441 S. ANAHEIM BLVD.
Lender's Address CITV TEL.NO.
ANAHEIM CA 772-1441
1 cerCify Ihat I have re�d [his application and state that the � .
above information is correct.I agree to cnmply�vith all C�x+nty . lIC NSE NQ� �1SS6BB CLASS C-20
<rtdinancet and S�ate la�es reguluting He�[ing,Vrn[ilsting and,
Air Conditioning,and iereby authorixe represcn tives �f[his ' SIiIi R4;VIi1251C I�Oft IiXPLANATONY LANGUAGI�:
Cuunty to en�er up�n �he abo��r-mtntion;d�ope� tnr � . �
��� cu, ,���rnoset y ,
. y
i
Signature of 1'rrmittee Date �
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