HomeMy WebLinkAbout0783A 45'OF2Iik.ki5�(�(J�I!'I�:NS:�IIU�U[CL�R.\TION � CE�81812-80) �►rPL��/���0�� FO� ��R��'�
[ herehy affirm [h�t I hare u' certificate nf consen[ to self �
insure,ur a certi(ic•s[e ot��brkers'Cumprnsalion Insurance,nr HEv,TiNG•VENTILi,TItrsG-r,IR C�NDITIONiiVG
a certified copy[hereof(Sec.38U0.�L'aIh.C.) /
Po(icS'No�'��'04�nm�:�ZS�" � L/l�G• py,/,/L•(
t��� COUNTY OF LOS ANGELcS
❑ CertifieScupy is;�areb>furnished. BUILDING ANDSAFETY
� Cer�i�i�d cepy is fileS�vith thc�oun[}'building inspeciion FOR APPLICANT TO F�LL IN �°L��L�ING��4��
rjj�p�;q:rt,:,�r,;:n�t'� �,/� y� /�
q�p�;��p / � (PRINT OR TYPE ONLYI 3 AD�RE55 �
1)aI2jC.:�. I��CFt��et�Ilo'�/�/C' __ . _ _ ___q _ � 1 _,CLj��__ �f
',6�!-� � 'LOCALITY �
CEftT1FIC:ITE OF'tklttitPTi :�I ItO:`.?!'J C RKk�.KS' NO. I TYPE Or APPL.IANCE OR EQUIPS1E!CT I� FEE �_/fl"/'2D�J��L
CO�IYEi\S,jl1U�ItiSGRAtiCb I � ^;EAREST,
(This sec[ion need not he cvmpEe[ed i� [he work imolved !aRsoaPTieN uNiT,oTu � ;CROSS 5T.�� � � ,� a
by [he permit is for one hundred dotlars (S100) ur less.) i ,,;rF��c1 au P�*oce,sEu�� � U
! cc:�if', th,,[ in the p�rforn,�u��uf t��c«��,rk f��r whieh ehfti 'ain Hnn;o�i.��urv�r,cr-^.^... . --- . I
pernd[ia istiued.I Shall nuc rmplu� a�y person ia any manne. ! I 1O � �
so us to become suli;ecl tn[he ll'orkers'Comprns„tion La�eo. �BOILER.6TL'------ --- -- ' ; - ' �
; . ' � AF'I+ROVALS � DATE � I`+SPcCT0��55:G".A?u1tE U
I �
Uatr Apptic�n�_'_._._. _ __.. _ PCOMPRESSOR,BTV—""_.."_'__. , n� � —_ ! — _ W
— � , 4 i � a
i �_....:.., �/�- •---1._.... � z
NOTICF.'I�O:\PPLIC4VT: tf,atter makinF[his Certific:itd nf 'VEN?iLP.TION SYSTEt.I � � —E F�NA� �� iL����__ � � 17 z//3o
F:remptiun, you ciiuuiu he�n:nr sahject tn Ihr 1�'rrzkers' � I �T �" f�`�-�(P
__—�y
C�imptrs�[ic�:i tir:nisi�>E:.�;:[h�L�li:�[C�,�e.Y��u mu�t f��fih. � i � b i
wiih iomp!y wi[h ' � ' `EVAPOHATNL°COOLER � � � �
ai.�ch ['ruyisu�ri; ��r ehi. permi[ shull 1�- � � _.......___—._�--_—� V _�[�laT�[:�I
decmcd rCvokrU, � �FURNACE� FAU_GRAVITY_' � �
Lli'h.titiF:U CUlV7H�t IUH.�I�h.C'LARA"CiON i}— FLOOR� _BTU._ '._ _—__ � �
i he:c`nt ;.fft rt rf [ I,m t' -� t. � �.t�SaJ:::�r.`f,::�,i:r i —' 'HEF.TEH: SJSF �.i�ED �'.1l ' �
`7 (cummrncm. i��S c i n 4GU)<t U'u�i n.7�t[:i:H.�r � WAIL . �
ncti�and i'r�fac ri„t i1 and r 1� --— - --- ----- - -- ---- - - -
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�ti1�2 1.II]rul��J ..!t;� ��J �
tt��<�. �G�Z�2�. �rL°I---- ��--�-��``-T;a� o�e__�;s�T_���
Lieeine IWumber ic CI;15S— j
� ,r�! 20-� ` rlu�.> S 4 sr�rr i �
Cuntraccor�D N/�TG.tr �j�:��_ -- �_ �j ;
� I am e�en;pt Trom thc licer:mg rey:iirements as 1 am� �� _ _---_'..._'____'___ ' :
i �
..
licensed architect nr � reki�tered pruftssiun3l cn�ine:r •e p{an che.ck fer,25��Of�beve. ��—_��
actine iu my� prnfe.sionat ca�e..ity Lti��rtion 70.7. f3ua� .1------...-...... ... ... ._....--_ __-.-. .-..---�--- �
B
�nc„and��r:;t:s:.i;;,^.s C:;;i,:�. ' PERMt7 ISSO!�u FwE S; ��r
' .------ --------- '
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tia nr I.r�.Nu.----,----,--Dat�— ¢ TOTFIL PEE ����
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HU\iL USitiLR-8i'il.i)I.li DECL;�I2ATICiV PLnN^HECK APPLICAN7 p
I herth: affirm tltat I am e•r�.npt f�un� [he C"oniracum'� �--- —_"�—'—_'_—' � .
I.icema La�+ fo: [pe fui!uµ'±;rK rrus;.;n (Sci.tion 7031.e. Rusi- �• [ �
ness and Profcssi��ns Cud�): AD�RESS + �0 7�3 P,
� � ,� � li �', i:� F ..
. as m.r.:: ;'th� ��,;;G:crt:. ,. •,.ork ard th��
structure i.r not int:ndrd ar uffered,for ;�le (Section ��GTY TEL.^�O. � ���� � �'�8
7U44,liu.ines�yn�l tq��.�fessinn=,('�,:i_), �
❑ -06VNER D S v, � I-• • � Cl S O
I,�s owncr uf the prnper[y. am esclucivzi}' con[racfing
Ki[h licensed cnntractors to cunstruct the prOj2c[ MAIL ,�Q�� �
(Scctior.?CJd,IIu,i�:c;.a arii�Froteaaiunti Cudej. ADDRESS � SD _��D� /7�/�i ; �• • • � Li,F�U
3
CITY /. 1�— TEL.NO.
COtiSTRGC:IIOtiLI':�UI\G:IGLNCY � W�.1LV 9�Y-�`yy/ � I L24�81
I hcreb3' dffirm tha[ [harr ia u cunstructiun lending uXtncy
for the perfurn:anec nf the �i�nrk fnr �rl�ich tf�is p2r�tti[ iti CONTRACTOFI !`A,. .. 1 /Lr�1�///L �(��-
issued(Scc.?U9?.Cic.C.). �/ l��M /TL /Y .f�N•� •
Lendcr's Nou,r .._.........._ ..... _ ❑A�RESS 7 G �SJ�`�J� s
Linder'sA�liiie.>_ _ i � t��v� �
� GTY D.l�dv/�.iL TEL.NO. ��7 :
/`_ �T ?
7 CCfLI(Y Ihal 1 hnl'C l��J lhl;ap�llliatt�J�l 3fld SIJte Lhel ihe $TQTE /- ---�-� LIC. /r f 0 . .
�bu�t infurmu[iun is c�irri-et.1 agree lu cuinVly�ci[h a�Il Coun15 1 ICENSE NO. 10SZ�Z C�ASS V �� ,
otdinancec and Stute latcs regWartin�Hca[in�.�'rntiln[ing:mti
Air Condi[iuning,:m,l hcrcby :wd�orirc rrVr��,tnta[i��es of this 51�6 RkVFKSt;FOR FXPI.ANA?O;?."LANGC.\GI.
Countl' [o enter upun [hv uhucr�man[iuucJ prupert} fur �
iutipec � �ur n•,
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