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WORKER'S COMPENSATION DECLARATION 200046 DPW 9/89 APPLICATION FOR PERMIT LIME GREEN:
76A364C
I heeel y'affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a celtified HEATYNG -VtNTILATING -AIR CONDITIONING �I
copy therefof(Sec.3800 Lab. 1`�C.) ( (�
Policy No. o?"ny r' t� "`� P COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
El Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRESS
r- PRINT OR TYPE ONLY
department. _ ( ) op
Date pplicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE 01 Z4
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU 40, !/d' 403
APPROVALS DATE INSPECTSIGNATURE
Date �y Applicant =�iL1 VENTILATION SYSTEM O
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Z,C
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL ^�
provisions or this permit shall be deemed revoked. ` FURNACE: FAUG xxITY
LICENSED CONTRACTORS DECLARATION / FLOOR -BTU o(i DO O 3 6-- VALIDATION
1 hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code, and my license is in full force and effect.
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License Number 6-13113 Lic.ClassCL
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Contractor/ // \ g_te J_ 21> L
EJI am exempt under Sec. Plan Check fee _. -Q U
B.BP.C.for this reason PERMIT ISSUING FEE Z/ - a=` O
Date: (4 0 0TA�f 231 5
5 w t :_ V
TOTAL FEE LU
Signature '.r'Y'
I IL
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affiFm that I am exempt from the Contractor's License Law NAME Z , wrjr } Z
for the following reason (Section 7031.5, Business and Professions �O /U T
Code): ADDRESS G
❑ I, as owner of the property, or my employees with wages �,Q/1>A�c cry
_)_t` )r's ,j '�:� 4
as their sole compensation, will do the work and the CITY / (/� TEL.NO. Ay- ra_
l structure is not intended or offered for sale (Section 7044, T� `"� t I 3231 - At(. '' •'
Business and Professions Code). OWNER ��C 1 !/L)� 4
F] 1, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there is a constructionpragency for CONTRACTOR
the performance of the work for which thiss permit Is issued s� a�
(Sec.3097,Civ. C.)
ADDRESS
Lender's Name
s V „ Lb�/► TEL.NO.
CJ CITY I% ) ( l O✓ /N
Lender's Address STATE v LIC. t
I certify that I have read this application and state that the above LICENSE NO. CLASS
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
pro py for inspection p rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
IGNATURE OF APPLICANT OR AGENT DATE