HomeMy WebLinkAbout1643A (9) 1 :•.!i`�'.'�y�ffirmS'Ie"7�11_�"l5.4TI���'Z„1RATION CEA 61 6(2-BO) A F'P L IC AT I O N FO FZ P E P.P!1 IT
RJ�Va�e a ertff�ca[e of cnncenl to self ! � /7
insure,or a certiticate of�yorkers'Compensstion Insurance,n� ; - � �,!
�certiredcnpytherent(Sec.)Soo,Lab.C.) HGATING-VENTILATING•AIR CONDITIONING u
Policy No. Company ,
� ❑ Certified cnpy�s nznny rurnisnrd. COUNTY OP LOS A:VGELES [3U1 LDING AND SAFETY
�7y, Certified cop5'is filed with�he countp building inspection '
t` dP rt• e t. ..-7�,^ FOR APPLICANT TO FILL IN oui�owc
Ilate��Applican[ �`3v. (PRINT OR TYPE ONLV)
ADDf7ESS ��G Pe�seG-fc,�,vi��s
� � . LOCALITY ��,,�,�,�3�/ �j/jY�
CGILfI1�1CATG OF EYF5IPTION P(20\1 R'ORKCRS' NO. TVPE OF APPLtANCE OR EQUIPMENT FEE
CO�iPENSATIONINSU2ANCE NEAREST -�7�w.�.� ���� a
� (This section nced 11ot bC Completed IP ihe WOIk invOlVed ABSORPTION UNIT,BTU CROSS ST, //v/n�� g'
by thc permit is for one hundrrd doqars (5100)or Iess.) DISTRICTNO aocEs�� ev �
� U �
I certify that in the perfnrmance,nf the wnrk for�vhich this AIR HANDLING UNIT,CFM I
permi�i5 issued,[shall n�t empl�y an5'person in any manner
Il� 0 —
so as tn become subject to Ihe Norkets'Compensation Laws. BOILER,BTU �
/ � APPftOVALS DATE INSVECTOR'SSiGNATUFlE W
Date Appllc3nt COh7PRESSOR,BTU_���� / ROUGH �, `L[ N
NOTICIS TO AVPLICANT:If,after making ihis Certificate nf VENTIlA710N SYSTEM � FINAL ��L ?
tixemption, you shnuld M1ecome subjec[ [o [he 15'orkers'
Compensation provisions of the Labor CoJr,You mus[forth-
with com i� ���ith zuch Evt.:o;ATivE cooLE: ' V LIDATION
p 3 provisions or this permit shatl be
deemedre��oked. FURNACE: FqU �AVITY/
LICF,NStiDCONTRACTORSDECLARATION I FLOOR� E37u r�'�_
l heret+y affirm ihat I am licensed under pfovition5 nf Chapter HEATER: SUSPENDED UNIT '
9 (commendng�vi1h Section 7000)nf Division 3 of the Busi� 1VALL %
ness and Prnftssinns Cudr,and my license is in full force snd . .
effect. . ��
Licrnsc Numbe3:���3Z Lic.Clas� ..
Contractnr�� Date� � .
� I�m exempt (rom the licensing requirements as !am a ,
licensed architect nr s registered profrssional engineer P�an eheek fee 25°6 of above.
actin; in my prnfeasinnal capacity (Secti�>n 7051, E�us-
iness and lkotessions CoAe). PERMIT ISSUING FEE S
Lic,ot Reg.No. Da[e TOTAL FEE $' $'a . - ` ���C J F4
HOS1G Ot1'NF:R-AU[LDER DECLA1t.aT10N pLqN CHECK APPLICANT � � t"' ����° ��
1 hereby affirm that I am exempt from�the Cnntractor's ', NAh1E - � '��3�F Q
License Law for the follo�ving reason (Sectinn^,03L5,IIusi- � ;�r.C`
neu and Pm(essions Code): ADORESS - -
� I, as mvner of[he praperty,will do the work and Ihe �. ' , ^
structure is mt intended nr nffered fur saie (Section - dTY TEL.NO. . . � O 9,2 F�'B�
7044,I3usiness and Professions Code). ��rM� �
❑ . OWNEFl �y� -
1,as owner of the property,am esclusively contracting
with licensed conttactnr5 t� cnn�fruct� �he project FAAIL q.f
(Section 7044,[3usinrss and Profassions Code). A�ORESSa�04� P�C'er�'ue./-/�e�s�lJ� -
CITV�7�� T.JI TEL.NO. � - �' )
CONSTRUCTION LBNDINC AGIiNCY J/����l�y� �'
1 hrreby aCfinn that therc is a construction Icnding asency � �� ,I_—R,'��� �� ,_ � .
for thc rerfnrm�nce of Ihe �5�ork fot ���hicli [his �ermit is CONTFACTOfi ���/-.7 ���f�t��� � . ' , ,
issued(Src.J09�,Civ.C.). . ' , - . � .
Lender's Name a�or�Ess�� ��! JrrL�ffjfE' . . . , . -
Lender's Addresi CITV R�j�f(�6y�f/�' �/'�T[L.NO. _ .
1 certify[hat I havc read this applica[ion and state Ihat the 3fJ.y,L�•7 W�t�
:�borc infarm�tion is correct.!agree tD compl5'��'��h all Coun[y LICENSE ND. CLa55 �
ordinances and State Isw�s mgulating lizating,Vrn�il�ting and . �
Air Conditioning,and hcreb5'suthorire repretentsti�'es of[his .SGG RGVF,RS[t POR GXVLANATOF2Y L.4NGUAGE
Count o r.,r upnn ihe aboee-mentioned propeny fot
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Si_ ..ture o Permit[��L - Da
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