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WORKERS'that
COMPENSATIONIhavecer4 cote of.cons APPLICATION FOR PERMIT
I hereby affirm that I have a cert�'ficate of.consent to self •
insure, or a tegifi5;e5*-of Wbdcers. CpmpensaI;lon'Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a c€rtified copy theteaf (Set 3800, Lab. C.) '76A364C e
-
Policy No.(o�42g2a Company furnished. Nn 20-0046 DPW 9/88
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
ertified copy is filed with the ty bui d' g i s - FOR APPLICANT TO FILL IN BUILDING 5
hon ZZZ
dep rtment. ADDRESS ISI
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE a
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROC"t BY
the permit is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM
permit is issued, I shall not employ any person in any manner -
so aS to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS ATE P DR5 SIG URE
Date Applicant COMPRESSOR, BTU ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER. A DA
with comply with such provisions or this permit 'shall be deem-
ed revoked. FURNACE: EAU GR VITY `
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect.
License Number l�al. `93�bc. Class ✓ a
Contractor Dat / — ,
❑ 1 am exempt under Sec. O
Plan check fee m
B.BP.C. for this re n. a
PERMIT ISSUING FEE $ vt
Date:
I I TOTAL FEE
Signature
OW11ER-El DECLAFKTION PLAN CHECK APPLICANT - -
hereby affirm that I am exempt from the Contractor's License pop.Law for the following reason (Section 7031.5, Business and NAME -
Professions Cade):
❑ I, as owner of the property, or my employees with ADDRESS y
wages as their sole compensation, w0I do the work and CITY TEL. NO �j
the structure is not intended or offered for sale(Section �Yh C/ 33077044, Business and Professions Code). OWNER 47.00
1, as owner of the property, am exclusively contracting • 1 ITEMS
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS - TOTAL 47. 00
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency for r CHECK 47.00
the performance of the work for which this permit is issued CONTRACTOR /•I , CHANGE(Sec. 3097, Civ. C.). rNE - •11Q
ADDRESS E
Lender's Name e
CITY N TEL. N .7 _ 0 13000-1131301 It :r/G0
Lender's Address
1 certifythat I have read this application and state that the STATE LIC. u07� i AM1Ur;.c
PP LICENSE NO. I 8 CLASS
above information is correct. I agree to comply with all County '
ordinance d _'tote laws rel ting t building construction,
and her author, represe ate of this County to enter
upon ove-m nt' ne opert for inspe honurposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
5 Is
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Sign re of Applicant or(P/enIr Dafe Os
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