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WORKER'S have
aceSATate of consent to 76A346DPW•9/89 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 I'
copy thereof(Sec.3800 Lab. C.) \ L1
Policy No. - ompany J COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished. / 2
J�
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING" �/t �9
PRINT OR TYPE ONLY) ADDRESS ��I r{� (/
department. Jame, (
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE 2 �G
C RTIFICATE OF EXEMPTION FROM WORKERS' NEAREST !
COMPENSATION INSURANCE CROSS ST.
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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify,that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU p
become subject to the Workers' Compensation Laws. d
COMPRESSOR,BTU a�i�
APPROVALS DATE INSPECTOR'S SIGNATURE
Date d Applicant 11LA VENTILATION SYSTEM
NOTICE!-TO APPL ANT:'If, after KyiTj this Cer ficate of ROUGH „r
Exemption,you should become subject a Workers' mpensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL �/
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAV TY a /
LICENSED CONTRACTORS DECLARATION FLOOR BTU ✓ J VALIDATION
I hereby affirm that Lam licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code, and my license is in full force and effect
License Number Lic.Class
IL
Contractor Date_C?f:! , O
❑ I am exempt under Sec. Plan Check fee
B.&P.C.for this reason PERMIT ISSUING FEE$ 0
Date: TOTAL FEE 6-5 W
Signature d
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT co
I hereby affirm that I am exempt from the Contractor's License Law NAME '
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS v
❑ I, as owner of the property, or my employees with wages ACCT■*
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, 33Q7 10
Business and Professions Code). OWNER t
❑
I, as owner,of the property, am exclusively contracting MAIL 1ITEMS
with licensed contractors to construct the project (Sec- ADDRESS ,CITY TEL.NO. Q ti;nE4�TOTAL �O mac'
tion 7044, Business and Professions Code).
,�yy CHECK
t 10r r r
CONSTRUCTION LENDING AGENCY 06� }� .CC
I hereby affirm that there is a construction lending agency for ( orkj
the performance of the work for which this permit Is issued CONTRACTOR CHANGE t
(Sec. 3097,Civ. C.).
ADDRESS ��--1ynn {'t fi{�t.
Lender's Name CITY 4W-84WI TEL.NO. � 00130-0001 83/2�f{jiy
Lender's Address STATE !llU�iTTTT.uo LIC. .5112 1 1 AM 9:11
I certify that I have read this application and state that the above LICENSE NO. f�• 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 pt inspection r ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
-�- - v
SIGNATUV APPLICANT OR AGENT DATE -