HomeMy Public PortalAbout5127 GOLDEN WEST AVE_Mechanical__ 7eA3
WORKERS' .f``QMP'EI•ISATION DECLARATION ' CE-8 (2 SO)' A L IC 0 I I-O R PERMIT
I hereby affirm that Z have r C6rtiflcate of contetrt to self
lnaure, or a certificate of Workers'.Compea-satiQ4In"ace,of HEATING-VENTILATINGTING-AIR CQNDITIQNINd
a eertifbd c ther �f,�}c.d80 .Ise.
~Policy xaE� P•nJ� i �� r
Certtfled dopy V fieroky turnLhed COUNTY'OF LOS`ANGEL�S BUIOING AND SAFETY
�Certiflad copy y.flledl,rifh the toil building
``T�� �..r�ri�++rgg6enn��t•p�� FOR APPLICANT
FIL�IN" BUILDING
IhiecN�11 �/APPllOan (PRINT OR TYPE ONLY) - ADbRE88�
P
C RI>FICATEOF EX) M lONTRO�I•WDItKERSI' NO• TYPEO.F APPLI^Rgf{ ORE70UIPMENTr FEE LOC LITY
COMEEN*l,TION INSURANCE. 1, 1 NEAREST'
01+ section Medd cot he•cU�l the work Involved. ABSORPTIONLJNIT;BYl!_ CROSS ST.
by Me pmwt is,,for -orefrundt (S1ODj orAee&) olsmcrl+o, eneY
I tprtl yjhst In the performanoe of the'wo&.for-which"thJs I HAND UNIT CFM i
peris )stbed, t shall not.emplby Any.perso❑ In,tiny msMsr. .
• so as fe becornkauliject to the Wofkert'•QbnipensationJAwi, BAIL TU
Dat6 Ilcinl ApeflOVALS 11A�E I��avecrdna>;rattiATURC
APP ~. CO P �SBOR TU' M1
ROUGH
.NQTME TO AQfdCA T.- It'aftsr making'ihte Ceitlfacgte of VENTILATIQt�SYSTEM FINAL
' ne1n,tlon,. , dhow f. becorire subiaot•ko the Workrr; r .
Ipmpenaatltin provisfpns oflha L'4"r Code%ynn must'fgrlh: , EVAPbRA��VE OOOL6R
wall'comply' With.such, provWorir of this permlt tfall be VALIDATT '
deerrtecJiaObked FURNACE-: FAU GRAVITY
Ll('1"NSF.D coNrRACTORS DECLAPATION FLOOR- -
I hereby♦ffftiD tflat I orn licenshd under prvvislbns of Mftpter I
Y � }iEAtJ=A: •.,8U$P�A(pED - UNIT• +.-
9 Ccomm6nttng with Section 7000} of DWbl4n,3:of the,Bual- ,WALL-
1, '
6a+ apd Professions Code;and My lieenaa la to full force and ,
effect;
hlceaseNumbe Ltc.Claalr
Contrtet tp _ _
I Ani exempt from the I1"iaing requkramtgtn u-I art ti L Y
ticonsed arc ecf or a registered pro nal ahldnaar P[an shack fee 1 %of'abbver O U a
acting ln"my�ProfOWbr ll cAPatify k30cV" 105% 'Airs
Jnou bnd Prgfg%J1bna Cbde). -PERMIT ISSUING FE;E$
i LIp..or Rat.No. Data TOTAL PEf
NOME OWNS—R.BtII],•DER DWLAIUk30•N'. '` K
PLANK APPLICANT:,i'
I gWby arfirm that I im gxe'm-pt-from•,tb6.Contrpctorl Licer" Lew for tht foliowiniv Y*"D (Section '7031%5,'Sual nes apo ProfesYlons Cole.):es o*ner pf ttfe prop", wfflilia work and fha structure hl•dot- intend6d or_gf1erad for' Life (3aCtf6n TEL, Nd,
7044 n lneu an Prof B a d eaklons coda).•.. i ?,e' 6E]. r yQ,
Lam( I ei owoar•of ifie ro 1� oTo.•2��'� .
t P pet*y, sin oschitf�ely coatrkctirili •.
with.11aeni &.-c,antrackoa to cgpstruct the . Project `'' MAJL
'(Section 7044,•Bustneaa and Pr6famioea Codas r ,i E3$ 8fa
CONSIRDCTION'thI1DLP16/%Ca-EN4''1 CITY
I hrorgby sPflrnt tha#•the��'pp it a cooalTuc n Ipnding agency
f�oorr the'.perfotrnance of'the work for',which• this perrnit is CONTRACT -
*vad Sea.3-0971 C'.iv.C:j, %
R 's Name DRQ
ba oat .. � SS
L.enao.6 Addrpu CITY' TEL. NO. r
-X'rertlfy-th>at.I Irave road this application "d sWe that the g ATS LIG
above infbrrrratloF is correct,I agree to comply with all County CLASS ti
oidlnS{rtta• Stats Insys reylrla k I3tlatirt�, Ventllttihg and 'i.
Air S o 1 ing,and,hereby e e rppraeniaJ3ves of this' SEE R-EV',RSE rOR"11'1,A�NATORY LANGUAGE
up t enter upon the b e-mentWn6d' pro rly for
iitga . tt°e . D •° -- - - -
Se keel- c`E e18.-1i70 " APPLICATION FOR PERMIT :
HEATING - VENTILATJNG - AIR C.ONOiTIDNING
COlUN'TY OF LOS ANGELES BUILDING
DEPARTMENT OF'COVNTY. ENGINEER ADDRESS
.-SUILPING AND SAFETY 'DIVISION LOCALtTY
i NEAREST
CROSS ST ,
AWS
FOR APPLI¢ANT TO FILL-IN ayN�
(PRINT OR TYPE ONLY) - - -
RAIL
No TYP,.E A SIZE OF E¢UIPMENTFEE ADDR�$S
' [6 BACK OF AtPL1CZATION
CITY T*FL.NO.
FORCE,q111 FURNACE, eTU ,
'7 CONTRACTOR T r
COMPRESSOR, U Apt?Rr�SS =a
VENTILATION FAN CITY TEL:`NO. '
LIST ALL OTHERS BELOW STATE LIC,
LICENSE NO. Y r f CLAS5'
J _ _ RO P PAOCI:96EBY
INSPECTION RISCO.
O
O
w
Mariibhock"fee, S ,rev9rse, '
FEF: Z: o
—97
''OTA ; FEE ;
PJ_AN-CHECK.APPLICAN.T F. %
NAME r 1. L 1
ADDRESS t. r '
CITY, TFL.NO.
I HKRFBY ACKNOWLEDGE T}iAT I HAVE 71[AD THIS APPLICATION � - • - -
AHD
BTATE THAT THE ABOVE Ij C•O"ECTAND ASRKE TO COIdPLY _
*ITH, AL4 ORDANANCED AND LAWp 0E6ULAtINe HEATING, VTNTI AP P}IQ VyLG DST[ Uil TORT SIG TURS' '
LATIMG, AIR CONDITIOIII-Nt.
ROUGH . � Q +
H . }IKRKBY CERTI AT I�AM NOT. ANG IN VIOLATJON -
OF CHATTER G, D1V1 IL
OF THS SU.IN S NO PR D110NAL FINAL
.f00[ OF.THE JTAr[ 'C FORNI A.
SIGNATURE PERMIT VA D TION CK.
-OP PERMITTEE
PLAN CHECK VALIDAOid CK, U M.O. CASH
g 9. 0