HomeMy WebLinkAbout0995A (5) WORKERS'COMPENSATIONDECLARAiION ' APPLICATION F,OR PEI�MIT �
I herebY offirm fhot I have a certificole of consent to self
;,,,,,,e;ar fi cerfifitole of Workers'comPe�Saro�i�s��a��a, - HEATING - VENTILATING - AIR CONDITIONING
or a cerrified copy thereof(Sec.3800,Lab:C.) 76A364G
T 57'fFT� F�7n�lJ ce-ais�aev.ioiei�
P❑olity No.�,2$Compony � . .
Ce�tified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
�Certified copy is filed with the coumy building inspec- FOR APPLICANT TO FILL IN BUIID�NG .z w�,L�V T
ADDRE55
hon dePar�men�. / (PRINT OR TYPE ONLV)
IU 7��� ��!/�� LOCALITY l�,
Dafe Applicant -� � �*Lf7l� T
NO. TYPE OF APPLIANGE OR E�UIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' � NEnREST
COMPENSATION INSURANCE - CROSSSi. L��Q �Y�
(Tht�s�cflon nead nol ba compbfad�i Iha work involvad by ABSORPTION UNIT,BTU Dis�ciC�uo. ROCFSSEo B
tho pormf}ic for one hundr�d doilars(SI00)or lesa.) �
I cerlify that in�the performance of the work for which this AIR HANDLING UNIT,CFM
�1!
permit is iss�ed,I shnll not employ any person in ony manner �
so as to become subjecf lo the Worken'Compensolion Laws. BOIIER,BTU ppPROVAlS DarE INSPECiOR'S S�GNATURE
' ('pMPRES50R,BTU O �O 0 � RpUGH
' Dafe APPlicant
NOTICE TO APPIICANT: If, after making Ihis Cerfifitale of VENTILATION SYSTEM FINnI ��5��'
Exemption, you should become subject to tha Workeri . �
Compensotion provisions of the Labor Code,you mu5f fo�ih- EVAPOFATIVE COOLER VALIDATION
winc �omply with suth p�ovislons or this pe�mi�sholl be .
deemedrevoked. FURNACE: FAU_GRAVITY � . '
LICENSED CONTRACTORS DECLARATION FLOOR BTU �
I hereby aifirm that I am licensed under provisions o(Chap�er 9 HEATER: SUSi'ENDE� UNIT_
`(tommencing wi�h Section 7000)of Division 3 of the Bosiness ' WA« � ' , �.
ond Professions Code,and my license is in full force and e{fett. �.�. �G u / - f' � ?�9 Q.5 A � O
License Number`��0 7z 3 ���,�lass C' Z�� � �f V
r� � S•� �`i � -� ► j�. • . • •$ OG
Contracror NIp �•�Dale �O�—�� � • •2 5,']5 �
❑ . V
I am exem t under Sec. x W
P Plan check fee • • •2 5 7 5� °�
N
B.BP.C.for�his reoson PERMIT ISSUING FEE S D S 1 Q O 7—�7 ?
Do�e: TOTAL FEE � s 7S
Signature
OWNER-BUIIDER DECLARATION MAN CHECK APPLICANT ' � ,
�hereby affirm thal I am e.emp�from thr Contractor's License .
law for ihe following reason(Settion 7031.5,Business ond NaME Q r�'����G� S(�U(L�5 �
Professions Code�: � 7
AD�RE55 �r�,,
❑ I, os owner ot Ihe properfy, or my employees wiih �'�.7�'N .
woges es their sole compensotion,will do�he work and ��TY �� � Gh NO.L�Z �Lf �
ihe slrucfu�e is not intended or offered for sale(Section . . .
7044,Business ond Professions Code).� �1 OwNER t•^' Q p.,¢a v�
❑ I,os owner af the property,om ezclusively�contracting "�NLt��3T U�S. � ,
wilh licensed contradors to constrotl the projed(Sec- '�A�L
lion 7044,Business ond Proiessions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY ' ' " TEC NO: ' ' "'"� � - �
I hereby offirm thallhere is a tonsfruction lending agency for _ ,
the periormonca of ihe work for whith this permi�is issued qRpR (��VSp�" SO�S
(Sec.3097.Civ.C.). .. . . . - . .. -�`
. . ADDRE55 �U L�,�S S(�-7 - . � � �
Lender's Nama
. citv a,l�1M Oc9N T_ ie�.NO. '`�� . ..
Lender's Address
STATE ' LIC.
I certiiy that I heve read this applicalion and sta�e tho�the tiCENSE NO.- Q/55 - — �� � --- -- � - - -�-- - � --- -
obove informarion is mrrect.I ogree to comply with all Couny � .
ordinances a�d 51o1e lows relating 10 building consiruction, _ _ _ _ . . _. . _ . _ . . �
ond here6 authorize repre ent lives of this County to enter
on _ ove emi p er�y i inspectio pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE . _ _.
ID 7 �
Sign.re oi Appllcam or Ageni Da�e . . . . . _ .. . . . ... . . . . . . . _..
� `
� _ ,. ...._ ...-._
, , ' , �
; ;
. ,; � ... � i'. ` , A
L , . . � � , , � .
�, v. . ..: ,// ,! � t; .
�. • � • i"�, � . � .
.._ : -- "� . � . ' . . � ..
Z : ' /,• , n,
N . . , . .
'fl -y 1 � �� - .
n+ . - . ' - ; -
7�0 . ��' _ ` - _ . :
N -. _ , .
O ; . -. i�`: ; , i, , � ,.
� , , i ,.
. . I. �
. . . . .
_ . " 's
. � . .... ' ' '"' I }. .
, _.... ..__ ; . -
_ . � .... : ' .. , .- " ; ' ,
, � '' � � , -- - ' , i ' , F
"i . - • .
� ' ' 1 , '
j I" i 1 '
1 ` `• • , N �
� • `,• I' � � ,1 �
� ' 1 - ' • � ' � � fA
'' ' � _ ., • _ '`.- . . � O .
� . ' N
1
; . , 1
_ • ` .
� � _
R ' ' . .
� � . . • ' ;.l '
! .. '
` ' u� �n(1 3"G � O'W n S .
� _. S ao oa o n o � �.�� v_. m c:
, . . . . � o�in cc °�W �� = �.io m � � N if �
, . ' Tc'.3-° m�O , ° �'a c� ° o H�"u o N�.`" `o Q N Q N N o `
p � o n s o �� . ,- a m Q a"�c.e-- �� ❑'" � c� 0 7,:�s� n o 0 0 �
, � . ° _ 4� 3 : oti �'�- �� b `• a-m a�'c o �c a�"�,.°� °�.o�'�'Q �v a� = �
c � o Q o � H.o.a< � v
' , 1 , - � � n � ' Q�•,a�'�£• p 0.3 0 ��- � ��. O o�•�� o�r-_'v.,u 3 ° 3- m
. . . , � . T N p p p S w ; .,' O -.O �p N.N � . =p y.T�,� �p -� : �l S` '7G
� • , o • ,II o � r'N —0 3 �; a�° ' :'° o � ovv ° p?.n 3n o N m° W
� . , , � c F � � o n m ��_ , � G .
_ -f � � m � . w � � 3 cL N,_, �'_. x-�-<. N c •+ o -
.. _ . "" . . ' . 3; j • ' _T'3D �.N ,�„ � � _.�0.�� � � '� o :°p'�'7w ., o,nRO It'� j N'p 0 r .
'n" n O N PJ 4 p Ci'",t� O y, ] N �c „3.H O N � 3 O
.' ' . . ' (D ' � . � � O u'.� a-.Oi. O O�.� �V` � a 0.� O' �+ ry 7 �T7 ^� C O �G G rn .
,�. . . �. p.: � a ^ N �'�ao To =� o �� .� a o�� `''n �- � a� x l �
. . ln N Q O p N 7 S � p II• "7 � 0 T c'D O� :` N � n' C7
,. ' . � � . � ^, S ,'o ,� _r C � W S� �0 O O � ;� O O � C .. � frt .
�' � ' i . ," . .' � . � n'mv,c�o`°o � c3 -c ��« o�'�' 30 � �� 430 m' � o ., [�' .
•`i - , . ^3�,� °o � c� o'�? o � n" °,3` m �,p° �.„'� o o ,A
� n � < c �- N, 3 �
'�, .. � �o a � o� N �9 f 3 0 � na4 u.-p• �,��r� -. .a.� 3 D .
/ . . . , . � _� a',w � . m q V �. O ?'C p p � O� N c O in j- .-1•
� , � a� n� 3 ovo-'-° ° a-� o° o �Q:x3N3oa'� °c.nn � O
' ' ` ' ' _ �'a� �c � ° �3 m n o� -+°�+ <� o a� � o�,� aj � 7 Z:
'� -.; ° �o o �'° ° Q^. N � e�
, � - °-., � S c .... 'a o�N a-..o . £ T"3- 5 a°3'` oo _ -
. . . , .� j �.o S� 7-e c Q v.fl ° c�9 m ry �o�p O'H p ��7 4 n - .
' �� -� H '�o n" �o = o ci° N o � ' �r a o �o-o � a _. . o
. . � . C.� ;V�c p? J rJ U� i Q �b O N � ' S O Cl'?T V' u'
' � �'H'O � O ti U � � ^ 7 � 7 '" T 4
S O O
_ , . � O CJ Q '? �� S„� a
_ O ��
i ,
_ �����,.,,.�.._...--�"'