HomeMy WebLinkAbout5820ARS`CJhRFVS.)[OPDECLARATION
76A364C
WORKIAPPLICATION FOR PERMITrS18 (2 80) E- `
1 Iterebv affirm that I have a cert:f cat of con nt to, self
fi iT1 J Y-VEtVT€ iS' 4F?C,^1F2 rCONDITIQNINGinsurz, or a certificate of R%orker<' Com easa:iun Insurance, or }_
a certified copy thereof (Sec. 3800 ;1
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YOiic7 No.___--. C'Ompany __ . - G(,3iJN'TY OF I..tiS }a.lVGEIe.S .. . - . BUILDING faNi3 SAFETY
Certified copy is hereby furnished.
wcerti€ted copy is tacit w.th th ounty 1, 'n6 inspection - flelf t.:. - -
AD
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aed /.
y FOR APPi.ICAN fi ADDRESS
PRINT OR TYPE ONLY -
O`"ALI Tv' '
O APPI:AN CE O EO PMEN f FEE .-- --
CLRfIFICATF OF FRF,1IPTIOV FROM WOR KL R$ N O, ;TYPE
NEP.RF$T
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CORr I'EVSA'fION IVSLY ANCF'" — - '— 'CROSS ST
Phis Section need not be Coninleted if the wort. .involved ABSORPTION UNIT, BTU.___ - /-`*--- ^^• •^^^^"'
DIST.CT N...
by the permit is for one hundred dollars (5100) or less.)
1 Roc
111IcertifythatintheperformanceoftheOrk >r wh clot thy,
Alp, HANDLING UNIT, CFNS
permit is issued, I shall not employ' at person to any naaiiner-(---
so as to become subject to tnc 54'ot'•,cts C"Pcosation Uw's.OI LER STU -I
r A PROVAiS IlateApol, CO. ESoOR, BT 1 _ — t'OUGNOfICI: .VENTILATION SYSTEM ciN A!
IN
INSPECTOR'S SIGNATURE
L_m(.lice, you shou!d become s.,bj.c, to the tb'urI,-'
Compensation provisions (if the Labor Code, you Must forth EVAPORATIVE COOLER I.. VALIDATION
with Com!A, with such provision, or this phren shall tie
deemed ravoked. - FURNACEFAD.-GRAVITY._—i
FLOO R.__--
LICI:NSF.D "ON! RACTORS DECLARATION
1 hereby affirm that 1 %in licensed under provisions of ChapterIHEATEfl. SUSPENDED UNITi
9 (commencing with S -mil 7000) of Drvlsurn 3 f the fl -i- 1h ALL __ ` _
tit--- nzss and Professions (lode, and m, license rs in full Race and j -
effect.
t_ic.^n,e Nu m/her--! c_Ctas:,c,
I m exempt from the licensing requirements as I,am a
fee DON@ ficc :sed m niicel or a registered professiona; enp;snezr
acing to my prdfes rona! ca Pactty (Section 7055, Bus-
18rt check LJ° O
ISS ANG I' E
Professions Code)
PEiRMIT
mess and
G-. F=
Lic or Reg. y
@loll t•, O\YNLR BIII:,DF'R' "s,L..II A'fION PLAN CHECKCK A PL.I CANT
r hereby affirm that I am exempt from the Coatmctors NAME
reasonLicenseLawforthefollowing (SecGot.7031.5, 13usi,
ness and Yrofessicous Cod'): ADDRESS
Di, as owner of tote properly, will do the, work and tl:e CITY TEL. NO.
struUure is tierintended 9r ofF ed fu sale (Section
7044. Bu in ani. P if i ins Code). O`sINE2 -.` _ _,_ _.-------- Gi : G
V s. s,
f/.r
1. as owner of ilii Property, am CinSly ely CUn tract ng
L_.F with licensed Cont -actor, to emnstrtict the pxojL'et TAIL
ADDRESSSecflon7044• Business and Pro z ,,jois.s „rod)
CITY /orfrC"y.a, TFL. N _chC
CONSTRUCTION LVNDIVC, 4Ln:\t
that there i a const tett >n Ierd ag t - 1 herehy affirm e
for of the work or vhicl this neri:.m is
v - -
CONTRACTOR
the nerforinaoce
issued Clea 3097, Civ. C.). e
Lender's Name __ -- - ADDRESS
Lender's Addrzss j! __-------. C TY TEL.
I certify that I have read this apphratrun and state that the
Ctiunty
g7pTE LIC
LICENSE N4 ,[ ( CLAS ,!
above infm•mation is si r r.ct. I agree to comply with all
ordinances u=le- txtr la- s regU aemg i- !eating. Vemitating and
lir Con iamng, and t r Ly .tuxhoru.e iepr ssantanves o: this
Coon`' to tr upon ',ova mentioned prupertY for
SF.I? REV VRSii FOR :KPLAr\A'CORY L4NGITAG?:
usp on nes.
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ULU
V) Z
l.ds"PEC7Ci3'S Ni?' ES
hereby ;ff>n;t Ii;a; 1 p-, from the fbntrzctoz's
T ic-'O. La".-; :;);- Vic .oaann (Jf: ('t [(3Pi 7,3.;1.5,
Rusueest andPr'o: ess:o•t: CcaP': Any .^lily rr :ov
WNI-17 regtdYres- a senna £pccastr •ca, ,t':er, i»:;^.rc=•e:
dernoifsi, or repair 6,,: , rxcrure, im'cr it.s issuance.
Cls, req.;:es time anplrvar for suc!i perms ro rrfe a
ez ,aierrr_ ;`;tai to roxdp:nc;ta to .
ircr.l. on, of die O,rwarw', Limse
t!
aw '.?amil:: f
mwencirg v„rh seccion "C1,10) ,f eibi,sx??` ,{ of h
usiress end Projes.eicu„ Code, or t:wt Y.•= i' e.er;rla
her ,from cnd rky eros for the sitebuF ezern;.rich. An,,,
4o7arfrn of Sre: non 703 i. S b-r --z, ,p,,kar:! ,`•Jr e remit
atb;'c+c•tc 3rz aacPe—r tc a c'ri pe,aeJ•:,r of ren r.tre trtar:
rtf e imadred doliars i 5500).:
1, as ou nes or the property .'N cc rhe w;>wk, and
flu structure is riot iatzndel3 , oi;e:ec for sal;.,
sec 7,,4 . _sim.,sr a,d '••f,^.ierrs Lode. ...r Cor.-
u_.Jr'Y LiC P:fs'e^ QR fleS:O! 6iPly to art .eY Of
i)rLj,crrj, ;Ilo bur[cc o, tr+; r,:'es 14?ree:,, cnd ra.P,n does
j"/T worts ..ri:se(f _umiic'eer Ihat .,uch i?nprc c^renis
e r.oi Wts sed or oife-aj Gr ;ail ff ,hc
uildhig or irlmpro,eme er is ,..Jid ,.;Am one year of
comp;e!:on. me” cwner-bWlae:will l/ai•e rhe Fi rd
of ,OrGving "bar he did icor bteiid or irreprr,e jJr :,-e
pP:rpose o;°;_a?sJ
J 1, as ettincr o the pfo!c y, am etcsr,siee'y con:
feaoting w'i;L+ (msec;=cL ca;`_: aciersto cess tract the projsar,
Section 7'iJ4, BP.v,7csi and M ofscion Cede: 77ie Corr-
f1Cd F1Y'S "iecn3e i'.4' jae, ROr a,"P y to a, y/P3{'f' Of
prorerry ,n $G»mss or i.:arrcves t,rere::,?. anci w&G
con: ,ocrs for such erojecrs rcith :r conrr,c;.r; sl 'iceneeai
ru: :e2aar ro r';a Cons;n,,or:e f ic4rise Lasv;.
e .-tm cxctnpf ur, ., :,-!.-----.--- z..--_._._--
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