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WORKER S COMPENSATION DECLARATION TOB0046 A uc PW 9/89 ' APPLICATION FO PCRMIT; I r, , E
I hereby affirm that I haver'a-certificate of consent to self Insure - ,
EN
or a certificate of WorkePs'Compensation'Irisurance or-a certified i
copy thereof(Sec 3800 Lab C) " rt ., :'`'HEATING-VENTILATING-AIR CONDITIONING
Policy No t' `" ~Company " -^ ' COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS r BUIL'D' ING AND SAFETY DIV
d copy
Certified is hereby furnished j
❑ Certified copy is filed with the county building'mspection _ 'FOR APPLICANT TO FILL IN �' BUILDING'
ADDRESS
department 4 s +I0 o (PRINT OR TYPE ONLY)
_r t , , < , ,
Date a° '1° Applicant + , , LOCALITY
t + .1 , . NO _ TYPE OF APPLIANCE OR EQUIPMENT r_ � FEE
•� 'CERTIFICATE OF EXEMPTION FROM WORKERS ; , NEAREST-1 +' `,, - .• -x ,
� COMPENSATION INSURANCE +'�- °' �' y� CROSS ST . • „t, t'
t fit *a Y ABSORPTION UNIT BTU ASSESSOR
(This section rni ed not�be'completed if the work involved by the - { ,A MAP BOOK ,+' ' PAGE PARCEL +
permit Is for,one hundred dollars($100)or lase) ., °' ° AIR HANDLING UNIT CFM/ �"ro " a- ,,
DISTRICT NO ^' PROCESSED BY L 5 +'
I certify that in the performance ofAhe work for which this permitIc
is Issued I shall not'employ.any person,In any manner so as to,, BOILER BTU
rs ; 1 P �� i•+ r
become sub/act to the WorkeCompensation Laws
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3 COMPRESSOR BTU * t
Date , ' Applicant r - i APPROVALS y r DATE INSPECTOR S SIGNATURE
PP VENTILATION SYSTEM
NOTICE-TO APPLICANT If after.making this Certificate ROUGH
Exemption you should become%ublect to the Workers Compensation EVAPORATIVE COOLER', ' rt
provisions of the Labor Code you must forthwith comply with such FINAL ,
provisions or this permit shall be deemed revoked FURNACE FAU ^ `GRAVITY t '^� ; .� •+°\r
• LICENSED CONTRACTORS DECLARATION, ` BTU ` t * ` e't ��*t VA IDATION
I hereby`affirm FLOOR'that I,am licensed under`provisions, Chapter 9 ," HEATER 'SUSPENDED UNIT-
(commencing
NIT(commencing with,Section 700 0)of Division 3 of the,Business and ,WALL `
Professions Code and my license Win full force and effect
License Number - Llc'Class
Contractor Date ` � . � ,
❑r I am exerript under Secy, _` i, Plan Check fee ^ r i r r y l ,�,
cc
B&P C for this reason`` PERMIT ISSUING FEE$ 4 - , _'* O
• Date ' , • r _ TOTAL FEE ' OD , 'tt - W
'Signature
LAN CHECK APPLICANT ' ' - - ' ` ' r ra�,�' ,I Z
' OWNER BUILDER DECLARATION _ v r ;
I hereby affirm that I am exempt from the Contractor s License Law NAME
.,for the following reason.(Section 7031 5 Business and Professions
_Code) 3 ADDRESS , rit ` 9
❑ I as owner of the property'or my employees with wages - -;
, + 1 Ys .t_aS, , FeLI_
r as their sole compensation well do the work and the CITY• , TEL NO / ,r
structure`is not Intended or offered,for sale(Section 7044
r r 'Business and Professions Code) ` OWNER
❑ „
” I asrowner of the property am exclusively contracting ' ^w „r ='• B tx,lllTr,l r25_-00
MAIL • , r t r r ,r 1 a. r+r;s
with licensed contractors to construct the pro/act (Sec- ADDRESS
tion 7044 Business and Professions Code) p- {. •`r `''-
1 CITY TEL NO F'AN
t ' ' CONSTRUCTION LENDING AGENCY /� +•
hereby affirm that there is a construction lending agency for
tN the performance of the work•fcplwhich this permit is issued CONTRACTOR
(Sec 3097 Civ C) ` i
• - ADDRESS " • ' ` - {
' Lender s Name
CITY TEL NO
qa Lender s Address ^ STATE LIC ` • e r- ' f
certify that I have read this application and state that the above LICENSE NO rCLASS • ', `i ` ' t,a
Information Is correct I agree to comply with all County ordinances
and State'lavis relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned - 'a r'� • , '`
property for inspection purpo as
Cj _ SEE REVERSE FOR EXPLANATORY LANGUAGE
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SIGNATURE OF APPLICANT OR AGENT fDATE f ' r '