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WORKER S COMPENSATION DECLARATION 20-0046 DPW 9/89
76A364C APPLICATION FOR PERMIT LIME GREEN
I hereby affirm that I have a certificate of consent to self Insure
or a certificate of Worker s Compensation Insurance or a certified t 4wHEATINt VENTILATING AIR CONDITIONING
copy thereof(Sec 3800 Lab C) - - F
Policy No r 3 y���� Company � COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
1�J Certified copy Is hereby furnished
❑ Certified co Is fled with the coun u In ms Ion FOR APPLICANT TO FILL-i-W BUILDING r
PY 9 ADDRESS BAL �� �
de art nt , (PRINT OR TYPE ONLY)
4
Date << Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
s CCROSS ST TIFICATE OF EXEMPTION FROM WORKEVS
NEAREST 1---o
COMPENSATION INSURANCE ' t tri [ifiC- Z<"j f JV t5
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($100)or less) AIR HANDLING UNIT CFM
F , DISTRICT NO P ESSED BV
I certify that In the performance of the work for which,this permit
Is Issued I shall not employ any person In any manner so as to BOILER BTU
become subject to the Workers Compensation Laws
"
COMPRESSOR BTU
APPROVALS DATE INSPECTOR 5 SIGNATURE
Date Applicant VENTILATION SYSTEM r
NOTICE TO APPLICANT If rafter making this Certificate of ROUGH '
Exemption you should become subject to'the Workers Compensation EVAPORATIVE COOLER '
provisions of the Labor Code ,you must forthwith comply with such w FINAL
provisions or this permit shall be deemed revoked FURNACE FAU TS GRAVITY 4 Vt
LICENSED CONTRACTORS DECLARATION Y FLOOR BTU loll —VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business and WALL rt
Professions Code and my f force and effect 4
O
License Number Llc Class tJ
/V(7fCJ`7l�OV Late ?It I C! - �cc �CT,ec 0
Contractor 3303 79.50 o
❑ I am exempt under Sec Plan check fee i
` 1 ITEMS o:
B&P C for this reason ° PERMIT ISSUING FEE$ �' z TUTr ��`O
` Date TOTAL FEE -0 I C HECK 79.510 W
SignaturePLAN CHECK APPLICANT C"GE 00' U)
OWNER BUILDER DECLARATION _ r ` f7FitY Z
I hereby affirm that I am exempt from the Contractors License Law NAME ,
for the following reason (Section 7031 5 Business and Professions '
Code) ADDRESS - 0000-0001 3/11/9L,,119nb
❑� { I as owner of the property or my employees with wages a 52437t3 1 FM O�
as tt eir sole compensation will do the work and the CITY I TEL NO
structure Is not Intended or offered for sale (Section 7044
Business and Professions Code) 1� f OWNER 301 j3 L � `
� ' ♦ r i
I as owner of the property am exclusively contracting MAIL �i
�r with licensed contractors to construct the project (Sec ADDRESS J t/ ( J ��
tion 7044 Business and Professions Code) t
CONSTRUCTION LENDING AGENCY CITY /]/Z, /�,?' TEL N04
I hereby affirm that there Is a construction lending agency for r-RJ v/ T w t 4 1
the performance of the work for which this permit Is Issued CONTRACTOR O
c
(Sec
3097 CIV (,)
ADDRESS L1211
Lender s Name , be
h CITY C, TELVNO It- `
Lender s Address STATE 7-11 lam/ LIC
� y
I certify that I have read this application and state that the above LICENSE NO CLASS F �-
information Is correct I agree to comply with all County ordinances _
and State laws relating builds construction and hereby authorize r _
representatives t Count o enter upon the above menti9ned t s
property for I Ion pur es' ��`r / SEE REVERSE FOR EXPLANATORY LANGUAGE Y '"
(�/( s
� L
SIGNATURE FAP OR AG T DATE
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