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h m that I'have a certificate
of consent to 76A346DPW9,89 APPLICATION FOR PERMIT LIME
76A364C GREEN,
I hereby affirm that I have a certificate of consent to self insure,
or a certificate c Worker's Compensation Insurance, or a certified HEATING-VENTILATING - AIR CONDITIONING
copy thereof(Sec.3800 Lab. C.)
Policy No/M Company �yCOUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑. Certified copy is hereby furnished.
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
de rtme (PRINT OR TYPE ONLY) ADDRESS
Date .� Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY C_
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
T.
!
CROSS S
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work involved by the ASSESSOR
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM MAP BOOK PAGE PARCEL
I certify that in the performance of the work for which this permit DISTRICT NO. PROCESSED BY
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 ��� 24
APPROVALS DATE-' INSPECTOR'S SIGNATURE
Date rC� y Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, afterdhe
ng this Cer icate of ROUGH , `
Exemption,you should become subject Workers' Co pensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL to—1 3
provisions or this permit shall be deemed revoked. FURNACE: FAU AVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU 0 v VALIDATION
I hereby affirm that I am 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
Contractor Date V
El am exempt under Sec. Plan Check fee 0
B.&P.C.for this reason PERMIT ISSUING FEE O
Date: TOTAL FEE !j
Signature
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law NAME , V
for the following reason (Section 7031.5, Business and Professions
Code): JL
❑ ADDRESS ACCT■T
I, as owner of the property, or my employees with wages ,,,,,fit 1 9
as their sole compensation, will do the work'and the 3307 l�}
P CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, TT[�MC
Business and Professions Code). OWNER I, 1 1 Lt t'
❑ I, as owner of the property,'am exclusively contracting MAIL �- T€ITn� i�i C'
with licensed contractors to construct the project (Sec- ADDRESS �7iO0 Cl frLl1 U i• t Ct:
tion 7044, Business and Professions Code). CHECK 10, ,_r.-r
CONSTRUCTION LENDING AGENCY CITY G�9r,may 3 TEL.NO. �y��2& CHANGE .011
I hereby affirm that there is a construction lending agency for CONTRACTOR l�� CHANGE
the performance of the work for which this permit Is issued fJ
(Sec.3097, Civ. C.). �,n - s�,5i 7
Lender's Name ADDRESS ... 6' Aq /� M^"(,4: j �'• - •0{'S{l •..DUt31 /8�20�92
CITY `(6`/�1 !/a�i/ EL.NO. � �! � 5120
Ji 20 � tilt 9�1t)
Lender's Address STATE ff LIC. /� 1
I certify that I have read this application and state that the above LICENSE NO. l���� 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 for inspection poses. �/� /
SEE REVERSE FOR EXPLANATORY LANGUAGE
S1GNATUrJF!`APFPLicANT OR AGE DATE