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WORKER'S COMPENSATION DECLARATION 46DPW9/89
76A364C APPLICATION FOR PERMIT LIMAE GREEN.
76A3
I hereby affirm that I have a certificate.of consent to self insure,
or a certificate of Worker's Compensat)on Insurance, or a certified HEATING - VENTILATING -AIR CONDITIONING
copy thereof(Sec.3800 Lab:C.)
Policy No. Z_7_:4bompany���� COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING.AND SAFETY DIV.
L�JI Certified copy is hereby furnished.
❑ Certified copy is filed with the county buil ng inspec' FOR APPLICANT TO FILL IN BUILDING
department. c,�7 (PRINT OR TYPE ONLY) ADDRESS
Date "/�' Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEM RO
FM ORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK PAGEG�f' 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
become subject to the Workers'Compensation Laws. �0
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 t
EVAPORATIVE COOLER ,. FINAL
provisions of the Labor Code, you must forthwith comply with such
provisions or this permit shall be deemed revoked. FURNACE: FAU GR VI VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License NumbertR�6!�( Sl�) Lic.Class v�L� 3
Contfactor19L o
ate V
El Plan check fee
I am exempt under Sec. O
BAP.C.for this reason PERMIT ISSUING FEE 41 7S
U
Date: TOTAL FEE A
Signature (n
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z
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
❑ I, as owner of the property, or my employees with wages =_t
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER I7_;I[�
❑ Il._p
a
I, as owner of the property, am exclusively contracting MAIL 55
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with•licensed contractors to construct the project (Sec- ADDRESS = s- i 'E;.'�_s 3
tion 7044, Business and Professions Code). CITY TEL.NO. P! ! =i_'HANIGE J
�
CONSTRUCTION LENDING AGENCY _
1 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'.). Jim i0clz-, , „€3 E=_I—f`tir Ti j ;'
-_/'-.
ADDRESS
Lender's Name ./JK/X 0a All 1l'5
=
�/� \} CITY TEL.NO.
Lender's Address A!! 1O Ag Ie u�f ,�"�A 1 K 'l-^�`� STATE — LIC.
I certify that I have read this application and state khat the above LICENSE NO. 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
proper f inspect' purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
NAT AP ICANT R AGENT DATE