HomeMy WebLinkAbout1308A WoqrERS•�o�rFeNsnnoNoeanennov APPLICATION FOR PERMIT �
I hereby a((Km�hot I have o cer�i(icare. of consrn��o self
insurc,or a cerr�f�caic of Workr,rs'Compe�so�ion Insu�ancr., . � HEATING - VENTILATING - AIR CONDITIONING
or a cerf�'fic�y��co((Sr�p 3ROOf.¢�.C,) ' �6n35<C � .
�[j7(J� !-f f:r.���n�� '�'r�CE.flIB�REV.10/Al)
F�licy I�lo� C����ny ' �Va[/ �
� Cerni�ed copy is here.by lu�n�shed. COUNTY OF LOS ANGELES �� � ,3 BUILDING AND FE �,
i�Ce�Yfied copy�s i+ed with thr,co�nty build�n�inspet- FOR APPLICANT TO FILL IN euno+r.G - -
J~Vion deparrmnnt ACDaCSS �Z
�p �� (' � (F71NT OR TVFE OVLY�
� 00���31—n��u�o�� � *U^�- LOCALITY����[j ,
NO. TYPE CF AF?LI110E C4 ECU:P.'FNT FFE
CERTIFICAiE OF EXEI.IPTION FRO'A VJORNERS' NE�GFST
COMFENSATION INSURANCE C4055 ST. �
(Thls to[tion naad nol be tomplalod IF the wark fnvolved 6y A95CRPTICN U41T,BTU DiS�x�c�rvU �w�c[55fD Pr
tha permlt is(or one hvndrad dollars(f100)or loss.)
I ceilify Ihat in�he p=rformancn.of the werk for which�his Ai4 HAhDII.'�'G UVIT,CF!.1 �Q _��r
permit is issuerl,1 shall nol r.mploy ony pr.rson in any monncr p01lER,DTU �
so as to becom^subjeci io ihe lYorkcri Compensa�ion Laws. a^r.ov.+is D E INS�'!RC4'S S;GNA7l10E
�a�r. opplimnl COVPRFSSO�,BT _ �`3�f 0� O� ROUGH �C7��' , y4���
NOTICE TO AF7LICANT: Ii, af�er making �his Certiiica�e of VENTILATIp�15Y5TEh1 FINaL ,j� �,�Q
Exnmption, you should becor�c subject to the 1'Jorkers' �
Compensa�ion provisions of Ihe LaF.or Cod^,yo�mvst forih- EVA1�+4ATNC COOIER VALIDATION
wiih comp!y �th such pro��sions or d�is pc.�*+�i s�aii be
d�amed revokad. �UvunCE: vnu C�pwiY
IICENSED CONTRACTORS DECIARAT�ON FIOCe 5ru dQ D �
I herPby a�firm thof I am licn.nsed un�er provis�o�s of Chopler 9 NFpTER: SUSPfN�E� UNIi_
(commencing with SeUlon 70D0)of Division 3 of rhe Dus�ness � ��fA«
nnd Professicns Cnde,and my licrn<o is in iull(orce and e!fect. -T'�/� 4
/���� / y �� o
license Numbcr� Lic.CI�ssL,G.��L� ► V
.�` fX
Controct _ _Doie f�� �
�
❑ V
I om ezempl und�r$ec. a� J Q H II a
Plan check fee •- N
6.8P.C.ior ihis�e�so� PERM17 ISSUING FEE S "' ' ' ' '8 —
Q,P:� D
� TOTAL FEE I •2 2 1,5 0
$ignafurr.
O.'JNER�DURDER DECLA4ATION PLAN CHFCK APPIICANT •'�C C L.�,O c=.i
I hr.reby nffirm thn�I am eaempt from the Controc�or's license
low for th�iollowing reason($ection 7031.5,Dusiness and Nt1"tE 0�,.3 Q-$4
Prcless�ons Codo�:
❑ 1, ns owner oi!hr. a eri nr m r.m lo rrs wi�h aCDRE:S
m n r, r r� r..
wo3�s os th=�r so�s comp=rsa��en,will do�ti�wo�k and
the s!ructure is not in�e�d=d or ofiered icr sole(Sec�ion CITY TEL.h0.
70:4,Rus�n=ss and Profess�ons Cod=). ' .
O�':NER
❑ I,as own^r of thr.propariy,am r.xclusivr.ly cnn+racfinq �. �� •
w�ih licens=d tcn'rottcrs�o construct Ihc p.ojcu(Sco ^'^'�
rton 704A,Bosiness and Pro(cts�ans Codr). �CDRE55 _ �0 _itlJiiAi '__
CONSTRLICTION IENDING AGFNCY ��•!�
CI , TE NO.
I here.by afiirm fhol Ihrre is a cons�ruction le�d��g ogenty for ,
�he performancr,of ihe work(or which�his�rtrmil is issu�d �04TRAC r'.
(Sec.3097,Civ.C.). . _ � .
AD'JRE55 /_Q � � -
lender's Nome " «� �—
� - TE�.�0 9�/- �
Lnnder's Address - — �y�
I cerf�(y ihat I ha�e reod this applicorion ond s+ore��hat th� �CCNS�NO. � CLa55 �u - �
obove informoiian is correct.I o�ree�o comply wi�h oll CouNy
ordinances ond Sta�e laws relarinq to building consrruction,
ond hereby o�ihorize repres=nto�ivcs of�his Counly lo enicr �
upon t s obovr.-men�io� p�op..riy for inspeciion purposr.s. SEE REVERSE FOR EXPLANATORY LANGUAGE
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