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WORKER'S I have
a certificate
of consent to 76A346DPW9/89 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.)
�
cy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ Certified co BUILDING
copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRESS SU 5j A A'5 5 ft"' � /--[/e
department. (PRINT OR TYPE ONLY)
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY T p �� e C i
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CL/ W / ��U Z 4
- CROSS ST. , � I'
COMPENSATION INSURANCE 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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit _g }�/
is issued, I shall not employ any person in any manner so as to
BOILER,BTU 8(I G
become subject to the Workers'Compensation Laws. 11
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
'provisions of the Labor Code, you must forthwith comply with such FINAL �
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter-9 HEATERSUSPENDED UNIT
:
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code, and my license is in full force and effect.
i
License Number Lic.Class �.>
CL
Contractor Date OU
❑ 1 am exempt under Sec. Plan Check fee
BAP.C.for this reason PERMIT ISSUING FEE$ & 0 0
Date: TOTAL FEE d, �� W
Signature (n
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z
I hereby affirm that I am exempt from the Contractor's License Law NAME /�/� / / �U y1• ,
for the following reason (Section 7031.5, Business and Professions .144 1 r G H ✓�—� ---
Code): ADDRESS le-CI ?-r•:4.T479 z�
I, as owner of the property, or my employees with wages -D-s
as their sole compensation, will do the work and the CITY %v�z^ P/P Cl TEL.NO.
structure is not intended or offered for sale (Section 7044, 1 h I;
Business and Professions Code). OWNE _ _ �• 55
❑ I, as owner of the property, am exclusively contracting s-) {; a
MAIL CHEM —.+•s ♦:
with licensed contractors to construct the project (Sec- ADDRESS s,; IE •
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO. H+ t,_� j„I:
:_ i1,
Ihereby affirm that there is a construction lending agency for CONTRACTOR 4'), -V �7 e ,
the performance of the work for which this permit Is issued
(Sec. 3097, Civ.C.). :•y.
ADDRESS ? `E l —i '�tl 1d_1_ 1 :3-'
Lender's Name y a j`ti
CITY TEL.NO.
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-in pe ti n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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SIGNATURE OF APPLICANT OR AGENT DATE -