HomeMy WebLinkAbout0643A (4) VlORKERS'COM.FENSATIONDFCIARATION AppLICATION FOR PERMIT �
I�hc�ehy affMm ihni I hovn.a ��I�ca:c of consent�o self
insu�n.,or a certificpte oi\'J��i com���:��� �-f s„���«, HEATING - VENTILATING - AIR CONDITIONING
or a ccrlificd ropy thr.re .✓(Sac.38. ,Lah. � � �,, 1,��E�3h'�
� ` ��'1 1 IIIxT�AF`i��p�v.ioiei�
POollcy No. Compony� '
Ccr�ified py is hcreby lurn's�✓nd. � COUNTY OF LOS ANGELES BUILDING AND SAfETY
�Cerr ed copy�s filed w . •he couniy bo�idi �nspe - FOR APPLICANT TO FILL IN CU!IDIVG � �������
li d=p riment. �DCRE55
1 (�R!NT C2 TVP�O'�'LV) J�
Da � P, �� � �«���TY �� mo��r�`1+2
� / NO. TVFE OF PPPIIANCE OR E(:U'?'7fNT (fE �
CERTIFIC �E OF EXFh1PTION F .A ' RKERS' NeacESi\�`,�n�N� � 1 V
O:'•FENSATIO.'J I�5 RANCE C205S ST,�� �
(Thls�aefi ns�d not ba eomplFtad if fhe wor involved by �g50RPfION UYIT,OTU r�s��cr no i�voeessio 9r
Ihe permil ts lor ona h�ndrad dollurs(f100)or lass.) A14 HANDLING U\IT,CFM � /v
I cerli(y thal in the perlor ce o!ihe werk fer which�his
pc�mi�is i�s� d,I sh�ll not c �oy any p��sc.in ny . nner e0'�ER,3TU
50(]S� b!'.0 TC SUb�^� / l`�5�O� n/! 5 w3. 4��Q�VGlS p�'f �^1�':CICR'S$IGN4lU�E
oai ,. rc ,�
CO.".'.PRESSC7.9TU �OOOo -�—� �0 e'� �eu��i ryj�• �—..
M1OTI E TO APPII /1NT: If, ouer mo q thi CcrGiitaM. of VFNTIIATICN SYSTFIA FI4Al b �
E.em. tion, you should becomc s•bjecr t, IhP \Ycrkcrs'
Com�Pns�ii�n��ovisions of Ihr.Lnbo Coda, ou must forlh- EVAPO4ATI\'E�OOLER VALIDATION
wi�h comnly w��h such pro��s�ons or , e�m�r sholl bc
dgomed re.roked. FUR!J4CE: FnU_G R�n�V��IY �-1
LICENSED CONTRACT02S DECLARATION F1004 nru�'(,J O �U
I hcreF.y a!�irm Ihnt I am licensrd ur�±rr provisio�s cf Chop'er 9 ��F�TEq: SU$^EN��D L'NIi_
'(commencing with Sec�ion 7000)a(Division 3 of thn.�usinrss ' �f�*«
and Pro�e!sions Cod^,ond my litr.nse is in full(orce and eifecl, ` , y
��� Q �L � LS o
Litense Numbe��t lic.Class � � ' lJ
co„�.o����� �� 11 `�J`5��„ I�-� :0 6 r�3 A o
�_ F
� I om exe.mpl�nd.r$e.c. ii • • • � •tl w
Plan check fee
6.8P.C.for ihis recsen � • �G��7 Jr '^
PERMIT ISSUING FEE S /v S� . , � ����� z
oarr:
TOTAL FEE /.z
s;9�a��« o�t a—a�
01VNCR�EiUItDE2 DECL�R;ITION Vl/1N CHFCK AFPIICANT
1 h=reby a�f�rm iha�1 om exempllrom�hr.Conhacror's licn.nse ,
taw for thn iol�owin�rcason(Sr.c�ion 7031.5, 6usiness and Nn:'f
r"rnle,svons Ccd���
❑ I, as ownnr of�h� r t or m em lo res with AC7GES5
rn-�^�r, r A r
wngr.s as iheir sole compr.nsat�on,w�ll do�he work nnd ,
the struciure.is no�iNended er offerr.d for sole(Section CiiY t(i.NO.
7044,6us�nr.ss o�d Profess�ons Code�. O� y�`��� a f - ��
❑ O'�:N�R v
I,�c ownor n(t�e property,am rxdusively coNmclinq �1 'l
with Gcensed tonhaclors lo conshucl Ihp projecl(Snt- q�D4E55 �`J J ����G �
tion 70�A,6usiness and Pralessions Cod�). � �
CONSTRUCT10.'J IENDING AGENCY Ciiv ������� • r.0.
I hereby nf(irm that�hero is a tons!ruction Iending agency(or ` ,
Ihe prrfermenca af Ih�work(er which this permN is issued � CCvian�Tp7 ��
(Sec.3097,Civ.C.).
ADC*E55 J �N� r� '
lender's Name I
OTY • l� TEL.N0.3 3 I 4.I l
Lender's Address �� N
STntC � lic. ��
I cerf�fy ihat I havr.reod this a�plicatien nnd s�nle Ihal�he pCFNSE NO. C1A55
a6ove in}ermotian is cerrect.I�gree�o comply wiih oll Coun�y
dinont�s and S'aic lows re.lating . building tons��uttion, �
n� 1 hereby auth,n c reprr.sen� '.�.s of ih�s C unfy io enlrr "
•e bove�nc i c � pm ' �inspe tion p rposes. ' SEE REVERSE FOR EXPLANATORY LANGUACE
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