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WOrm'th t I ri a gefti DECLARATION APPLICATION
PP ICA TION FOR PERMIT
A P9 IL i.P'i RCI FOR PERMIT
I'ILVE 1
I hereby affirm'that I hove a cell ificafe.of consent to self
insure, or a-certificate of Workers' Compensation Insurance, ,6A864c' HEATING • VENTILATING - AIR CONDITIONING ,
or a certified copy thereof (Sec. 3800, Lob, C.)
20-0046 DPW 9/88 '
Policy No. Company -
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY,
F]', Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDINGtion d artment. , ADDRESS �•'`� !! IJ �' _
(PRINT OR TYPE ONLY)
Dale QApplicant ! LOCALITY
t NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST -
COMPENSATION INSURANCE CROSS ST. X & 7d'd/I .S
(This section need not be completed if the work Involved by ABSORPTION UNIT, BTU DISTRICT No. PROCE E By
the permit is for one hundred dollars ($100) or less.) r/.' a�
certify,that in the performance of the work for which this AIR HANDLING UNIT, CFM !✓1
permit is issued, I shall not employ any person in any manner,
so as to become subject to the Workers' Compensation Laws. BOILER, BTU1 / - APPROVALS r TE wsPECTO s SIGNAiuRE
COMPRESSOR, BTU %D D b o ROUGH
Date Applicant
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 ALI ATION
withcomply with such provisions or this permit shall be deem-
ed revoked.• / FURNACE: FAU_ RAVITV �i - P,
LICENSED CONTRACTORS DECLARATION FLOOR —BTU::— (�
hereby affirm that I am licensed under provisions of Chapter 9 HEATER:' 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. JV T1,e d
License Number Lic. Class Zf2 J " � O
i7V D u
Contractors'��+�'� xTate
'❑ . I am exempt under Sec•
PlaIn check fee W
B.BP.C..for-this reason' a
PERMIT ISSUING FEE $ z
Date: �9-�
Signature - TOTAL FEE oV
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT "
.I hereby affirm that I am exempt from the Contrdctor's License D ..
Law for the following,reason (Section 7031.5, Business and' NAME ;
Professions Code):
.� I, as owner of the Property,, ADDRESS-
p p y,'�or my employees with ACCT.i
wages as their sole compensation, will do the work andCITY. --. TEL. NO. �-.j)7 c5,1;Q
the structure is not intended or offered for sale (Section JJ
7044, Business and Professions Code). OWNERI ITEM:
I, as owner of the property, am exclusively contracting �iTX� Crd� ''
with licensed contractors to construct the project (Sec- MAIL
ADDRESS 7k"6 TOTAL c� e ��
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY �' S B EL. NO. CHECK 55.CI[I
I hereby affirm that there is o construction lending agency for (: ,IiO
the performance of the work for which this permit is issued CONTRACTOR L D CHANGE
(Sec. 3097, Civ. C.).
ADDRESS // 3 '.
Lender's Name p - 0000-010101' II 9/9U
CITY J rJ J TEL. NO.X�'
Lender's Address STATE -�—+` c./ LIC. �c
I certifythat 1 have read this application and slate that theCLASS '\ X139 1 AM 9a. J
PP CENSE NO. _(� 73 {�
above information is correct. I agree to comply with all County i
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
theabove-mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent 6.1e, _ -
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