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WORKER'S COMPENSATION DECLARATION 260946 DPW 9,89 APPLICATION FOR PERMIT LIME GREEN,
6A364C
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 -
copy thereof(Sec.
3800 Lab. C.)
Policy NS1 Company M7 COUNTY OF LOS ANGELES . DEPT OF PUBLIC WORKS . BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the count building Ins action FOR APPLICANT TO FILL IN BUILDING
department. y g (PRINT OR TYPE ONLY) ADDRESS 06 _O "v
LOCALITY
Date f 1_ Applican NO. TYPE OF APPLIANCE OR EQUIPMENT FEE � ��`
Ir
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST �y ' '
COMPENSATION INSURANCE CROSS S
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 '
DISTPICi NO. PRCCE$$E06V
I certify that in the performance of the�wgik 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.
COMPRESSOR,BTU ?A/
1�O
APPROVAL$ DATE INSPECTORS SIO RE
Date• Applicant - VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption, you should become subject loathe Workers' Compensation EVAPORATIVE COOLER (J
provisions of the Labor Code, you must forthwith comply with such FINAL O
provisions or this permit shall be deemed revoked. / FURNACE: FAU_GRAVITY
LICENSED CONTRACTORS DECLARATION l FLOOR BTU Q V LI ATION
I hereby affirm that I am licensed under provisions oVChapter 9 SUSPENDED—UNIT—
(commencing
USPENDED UNIT—(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL '
Professions V
Code,and my license is in full force and effect.
License Number 27/�� Lic.ClassL�
/ V'
/�� y - 23 0
Contractor-F`--i-' Date itir_LI :a
❑ Plan check fee - -Ic c
am exempt under Sec. 3-507 t.I,Q.I cc
B.AP.C.for this reason PERMIT ISSUING FEE $ 1 Ii=i S O
1 ' �rl�
`. .Date: TOTAL FEE TI)ZHLc m : c W
Signature /�- _ d
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT {_1�iwEthc� �J.4J Z
I hereby affirm that f am exempt from the Contractors License Law ' NAME - - - - -, - C.NANGE .00
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS
❑. 1, as owner of the property, or my employees with.wages 55,,ll 11 r--
as their sole compensation, will do the work.and the CITY TEL.NO. IJVIII�—U�iJt Yj 719`
structure is not intended or offered for sale (Section 7044, n n i 7.at 11:5S
Business and Professions Code). OWNER ]LQV 1 I-II I
❑ 1, as owner of the property, am exclusively contracting MAIL 0 `
with licensed contractors to construct the project (Sec- ADDRESS 5—
tion 7044, Business and Professions Code). -
CONSTRUCTION LENDING AGENCY CITY l TEL.NO -
I 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.).
. - ADDRESS
Lender's Name /v[
CITY ,TEL.NO. -
r
Lender's Address STATE
I certify that I have read this application and state that the above LICENSENO. }J Q ICASS
information is correct. I agree to comply with all County ortlinances -
and State.laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
prope for inspection rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
5ITINIATUROF APPLICR AGENT DATE