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HomeMy WebLinkAbout1308A (7) 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 �� _�o�'��-� s�g�niom cl nppumnr w tigen� omn � ' t . . � ".� � t . % � . .. - a . . ` .I� �. .. . . I � .!�.� _ , .. ' ' y i �• ... �,I ` � ��� . � :y ' ' � i . ' . � ' 1y• �- � � . � . f� r� �`'r , ` . . ., � � - r.� . � . ��� . i ' �- . . o � • ,:- 2•: N r�� �ff �• . ' Z . � O N � ' � :i , . � , j ri `, •� , ' � . �'� 1 ' . f ' ; ." ; ' ^� + 4 . ,,. ;. ( t .`/ 1 f� l /� �. � � � � ' -� • !/'• O .,` .j�.' �, ' yfT- •J' .'4., '� ` i � �� . �/� � , � m , `. 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