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WORKER'S COMPENSATION DECLARATION 720-0046 6A364C PW 9/89 LL Apron �CA��®nu� FOR PERMIT -
I hereby affirm that I have a certificate of consent to self insure, ! udu ,� \v)
or a'certificate of worker's Compensation Insurance, or a certified HEATING.-VENTIL°,T NG'-AIR CONDITIONING
copy thereof(Sec.3800 Lab. C.) '
Policy No. Company COUNTY OF LOS ANGELES DEPT-OF PEIBLIC WORKS BUILDINGANDSAFETY DIV.
❑ Certified'copy is hereby furnished .
❑ Certified copy is filed with the county building.inspection FOR APPLICANT TO FILL IN BUILDING .
department. (PRINT,OR TYPE ONLY) ADDRESS
LOCALITY / m.
Date Applicant NO.. TYPE OF APPLIANCE OR.EQUIPMENT•, FEE
NEAREST / •'
CERTIFICATE OF EXEMPTION FROM WORKER$: 'CROSS ST. _:7.0)'' �Q!
COMPENSATION INSURANCE. ABSORPTION UNIT,BTU :
This section need not be com leted'if the work Involved b the ASSESSOR'
( P y MAP BOOK PAGE�J PARCELD` '
permit is for one hundred dollars($100)or less.) ` AIR HANDLING UNIT,'CFM
_ DISTRICT NO. PROCESSED BY .
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTUjf
become subject to the Workers'Compensation Laws:
COMPRESSOR,BTU
_ - APPROVALS' DATE INSPECTOR'S SIGNATURE -
Date Applicant VENTILATION SYSTEM
NOTICE TO-APPLICANT: If, after making this"Certificate of ROUGH 01
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of.the Labor Code, you must forthwith comply with such FINAL —Z
' provisions or this permit shall be deemed revoked. FURNACE: FAU GR TY
LICENSED CONTRACTORS DECLARATION FLOOR BTU l4 VALIDATION
hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division`3 of the Business and. HEATER: WALL
Professions Code,and my license�is'in full force and effect.
License Number Lic.Class
.
Contractor Date ACCT e
Plan check fee J�OJ 114010
I am exempt under Sec. � " • `'
.. 1 .ITE115
B.&P.C.for this reason PERMIT ISSUING FEE,$ O.
l�'.`
Date: TOTAL FEE O . TOTAL o U
u
Signature CHECK 114, 10 GW..
OWNER-BUILDER DECLARATION "` PLAN CHECK APPLICANT
CHANGE ., . -00 z
I hereby affirm that 1 am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions D ,.
° e): ADDRESS .-3/21/96
3/21/96
I, as owner of the property, or my employees with wages t - hpyI tt
as their sole compensation, will.do the work and the CITY TEL.NO. 544'9 .1 A1111° P2
'"structure is not intended or offered for sale (Section 7044,
Business and Professions Code). LO OWNERI E /� r
I, as owner of the• ro ert ~ N/� A
p p y','am exclusively contracting. MAIL �}
with licensed contractors to construct the project (Sec- ADDRESS �jQ �— QV / V 'if,
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY e_� le f TEL.NO.
I hereby affirm that there is a construction lending a jency for CONTRACTOR
the performance of the work.for which this.permlt.ls issued
(Sec.3097,Civ.'C.). " D
ADDRESS
Lender's Name '
CITY TEL.NO:
Lender's Address STATE LIC.
I certify that I have read this application and state that 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
pro e y for inspecti n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
-VIGWATURE OF APPLICANT OR AGENT DATE - -