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DECLARAT
WORKER'S I have
a certificate
of consent to 76A346DPW9/69 APPLICATION FOR PERMIT LIME GREEN
76A364C
I hereby affirm that I have a certificate of consent to self insure,
or-a certificate of Worker's Compensation Insurance, or a certified HEATING -VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab. C.) `J
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
❑ Certified copy'is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING D /l
ADDRESS
department. (PRINT OR TYPE ONLY)
Date Applicant LOCALITY
- NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. �S 7T1,R A s DY
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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PR ces D av
I certify that in the performance.of the work for which this permit
is issued, I shall not employ any person in any manner so as to I BOILER,BTU � �q G i p
become subject to the Workers'Compensation Laws. (J 0
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU V LID TION
hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED ---UNIT
—
(commencing(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Number Lic.Class
Contractor Date O
❑ I am exempt under Sec. Plan Check fee U
Q
B.&P.C.for this reason PERMIT ISSUING FEE$ O
Date: TOTAL FEE Q W
Signature 0..
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z
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): ADDRESS
I, as owner of the property, or my employees with wages 9
as their sole compensation, will do the work and the CITYTEL.NO.
structure is not intended or offered for sale (Section 7044, T� —
Business and Professions Code). OWNERL
p r 1'''=1 =
H~HE-1yQ, 14 s'Wi Sv
❑ I, as owner of the property, am exclusively contracting MAIL ;(�";��
with licensed contractors to construct the project (Sec- ADDRESS 5 �N _€
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL. SCLNxe
I hereby a
erfoffirm that there is a construction lending agency for , 4-•HFi�`E
the prmance of the work for which this permit Is issued CONTRACTOR
(Sec.3097, Civ.C.).
ADDRESS 3
Lender's Name
CITY TEL.NO.
3566 c y E
e-S_�'
Lender's Address STATE LIC.
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
property for insspea2c it purpose / SEE REVERSE FOR EXPLANATORY LANGUAGE
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SIGNATURE OWPPLICANT OR AGENT DATE