HomeMy WebLinkAbout1702A (10) u'°RKERS•`°"'�E"SAT'°"°E""R"T'°" ' APPLICATION FOR PERMIT �
I hrreby af(km iha�I hove a cerriiiw�e of cons=M�o sr.l(�
I�Sl1IP,O!f1 CPlIiIiCO1P.Of NJOikf'�S eomAonsoti0n�nsu�ance, HEATING - VENTILATING - AIR CONDITIONING
ar a cerli(ied co�y ihereof 15^c.?3 Lab.C.) � 76a]neC
� ��y /�� ��� � CE-018(F'.V.10�81)
Policy No�j{(W(���7Compan _{.4!1L`^�C�
� Cerrfied cepy is hereby furnished. � COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Ccrrfied topy�s f�led w++h thc cou�ty bu�ld�ng tnspec- FOR APPLICANT TO FILL IN ^Unci"i�
��o�dP.PO/�mC��. (P71NT O4 TYf'F O4'LY) FCD�E55 ����'C P.�AS
p���. .�i��`�aa����a�� � � io:nurv Di1�A1P�l.n /�R �.q
Np, TVC��F AD7�IANCE CQ FQUI7!lENT FCE
CERTIFICATE OF EXE�"�TION FROM11 YlO4KE NEaaEST
COMPENSATION INSURI,NCE CRC55 ST.
(Thls sacllon need nol 6v complaled 1!fhe work fnvolved by AM1SC��TIOV UNIT,BTU p�yi���i H�� r�p(FS'fD P.v
tha parmil is For one hundred dollors(5100)or le�f.)
AIR HANDIItiG UNIT,CFM �
I certify ttiat in Ihe p?rformante ef the werk fer which this (
permil is issurtd,I sh�ll nol employ any perxon in any mo.^.n?r -
50 OS 10�]�COI�IP SUh�=c��o�hr.Vlorkrrs'C�mrrns�tion Laws. �10'LER,BTU P�`RCYPIS C?iE IN�MCICP"5$�CiNAi��PE
ooro ^r-a���a„� co`.'PR:SSOR.BTU��� � C1 O� ucucU, }„ s � �c �S V (/. r •.�.�
NOTICE TO APPLICANT: If, afrer mn4ing thls Ceril(ica!e oF VFNTIInTiO^15VSTF!.1 F�vnL S ` � `(ya)y/
Exemplion, yoo should bncome subject io the �Yorke.rs'
Campenso!ion prov�s�ons ol the Lahor Codr.,ynu must fonh- FvaroaaiivE COOiE2 � VALIDATION
with comply wtth such provis�ons or �h�s perm�i shnll be
d^emrd rr.voked. FUcvt,CE: FAU G�,.a�v,1TY
IICENSED CONTRACTORS CECI�RATION � nOOe sru}c�0_,�� l U OO
I h?rrby aflirr�Ihol l om licrnsrd�ndPr provisions c(Chcr rr 9 �+cqTFR: �US�Ft�'CC17 U4�T_
� �(cemmrncin�wi�h Sec�ion 7000)ef Divisian 3 al Ihe f3usinrss � ti��A«
and Professions Codc,nnd my licrnsc is in full(o�cr,and Pffatl. ' y
lirense Nvmber���`�� lic.Closs "�� \ � , O
I � c
CoNroc Datc�� �
❑ I am exempl ndcr Sec. V
Plcn check fee w
ES.BP.e.io�ih�s reoson PERMIT ISSUING FEE S N
Dnrr:
10 z
S���o�u�c TOTAL FEE � :�1 !Q[�i
OYlNER�f!UIIOER DECLARATION RAH C��FCK ACP�IUN7 i?• ' • ' '�
I hrreby affirm thot I nm exemrl(rom thr.Ca^hactor's Licen�e ,
Law for thc lollow�nc�rrnson(S++cticn 7031.5, Rus�nrss ond nns�E � • •4�^J n
pro!r.ss�cns Ccdc�: '
❑ I, os owncr a(th�propPrty, or my ernploy�rs with �DDFE55 • • •����•5��
woges os iheir sole compensotion,w�ll do the work and �ifY ifL.NO �
thr,siruciurr is not in�end^d c�effered fcr sr.lr.�S^cf�on �7'����J
70:A,�usincss a�d�rolessin�s Cnd�).
❑ O'.L'•�'FR ��� 1
I.as owner of the prep^�iy,am e.dusively cor.tracling _N
w�ih litensed tont.acta.s to co�s4o:��he project(Srtc- r""�
iion 7044,3usiness nnd Prcir.ssions Codr,). A9C=ESS a2v ,�-G LC i-�
CONSTRUCTION IENDiNG AGENCV pTy ��� rn.Np _
1 herc6y nffi�m ih�l�hr.re,is a construction lending agency fer
thr,performnnce of�h=work for which this permit is issurd CCNT� �y � ,
(Scc.3097.Civ.C.). —
aoc�ess,S �G-� CLJ
l^ndcr's Nnmc �
. CIiV �L� /��` �TEL.NO�� F�
lender's Address ����
Sil11E +t LIC.
I cerlify Ihol I have read�his r.pplication�nd s�a!rt rfiat ihe LiCENSE NO.p,�7�Yl CLASS U
above intcrmo�ion is ccrrrct.I ar,rec to cemply wirh a�l Coun�y
ord�nancr.s ond Sia�c laws rctar�nq io building constr�ction,
and hereby authorizc re�rrsr.nto'ives ef this Co�nly lo�n!rr
upon ihn. bove�meniioned property for I�spect�on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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