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f WORKER'S COMPENSATION DECLARATION 76A346 DPW 9/89 "APPLICATION FOR PERMIT
76A364C
I hei'aby affirm that I have a certificate-of consent to,self insure, J Y or a cbruficate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING, it
copy thereof(Sec.3800 Lab C.)
Policy NotmQa��/4/ /old dJV�' COUNTY OF LOS-ANGELES DEPT OF-PUBLIC WORKS 'BUILDING AND SAFETY DIV.
Certified copy is hereby.furnished..
Certified co is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
PY 9 P ADDRESS '
dep rtment. / 4 (PRINT OR TYPE ONLY)
Date -AP licant
l� - NO ' TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' ANEARESST
T
COMPENSATION INSURANCE CROSS O
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.d ollars($100).or less.), AIR HANDLING UNIT,CFM DisrRicT No PROCESSED BY
certify that in the'perfo�mance of the work for•which this.permit
Is Issued, I shall not employ a6y"person in any manner so as to BOILER,BTU
became subject to the Workers'Compensation Laws
COMPRESSOR,BTU
- - APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM - '•
NOTICE TO APPLICANT If, after making this Certificate of ROUGH
Exemption,you should become subject'to'the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you'in ust''forUiwith comply with such FINAL
provisions or this permit shall-be•deemed•revoked. FURNACE FAU GRAVITv IDATION
LICENSED CONTRACTORS'DECLARATION FLOOR - ' BTU
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT /
45
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and'my license is in full force and effect.
License Number T��/� e Lio Class " .
Contactor tom'-` V
❑ Plan check fee t�Q
I am exempt under Sec / i `O :'Q.
B.&P.0 for this reason PERMIT ISSUING FEE$ / `J'�.-' 'l i�' 0.
l�
Date. TOTAL FEE �il � W
Signature
1. PLAN CHECK APPLICANT _
OWNER-BUILDER DECLARATION ^v. Z_
I hereby affirmahat I am exempt from the Contractor's License Law NAME , +j
for.the following reason'(Section'7031.5; Business and Professions "� _
Code): ADDRESS fa,
':I °a
❑ I,-as owner of the property, or my employees with wages --.—
as their sole'compensation, will do the work and the CITY TEL NO - t'`i -
structure is not intended or offered for sale (Section 7044,
-Business and Professions Code). OWNER''
❑ I, as',ownerof the•property, am exclusively contracting D T'(i7
HL 5'�-�_ 0D `
MAIL
with licensed contractors to construct the project (Sec- ADDRESS ri:
'tion 7044,Business and Professions Code).
CITY EL NO .i;!�HttE'.31
CONSTRUCTION LENDING AGENCY ALL C -
I hereby.affirm that there is a construction lending-agency for CONTRACTOR
the performance of the work for which this permit is issued ( - - —^
(Sec 3097,Civ'C
ADDRESS' DC?,SJ J' - _ F1IJLi—!':i_�I_ ..:... ..5:t�""'1',f:•t
Lender's Name `... _ - i . iiF _ _._ ..:{it? l.5"
CITY N- TEL.NO
Lender's Address STATE 9. LIC: _ t•. .c
certify that I have read this application and state that the above LICENSE NO. CLASS .� Q
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'
propert for " spe on purposes. SEE REVERSE-FOR EXPLANATORY LANGUAGE
SIG U P L CANT OR AGENT DATE,-/