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WORKER'S I have
a certificate
of consent to 76A346DPW9/69 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
copy thereof(Sec.3800 La "
I' y No. Company COAL f,4�P;A"T y COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certifie copy Is hereby furnished.
Certified co Is filed with the count building inspection FOR APPLICANT TO FILL IN BUILDING
PY Y 9 P tet' �CT"t
. dADDRESS
department C/�; > �- (PRINT OR TYPE ONLY) .
Date v~ Applica —( LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXE FROM WORKERS' NEAREST
CROSS ST.
COMPENSATIO FROM
ABSORPTION UNIT,BTU
This section need not be completed if the work involved ASSESSOR
( b P Y the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws. D�
COMPRESSOR,BTU
' � APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER -
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY �U VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR —BTU
'I hereby"affirm that I am licensed.under provisions of Chapter 9 SUSPENDED I UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect. O y���ie
.� 11 �lb "l 5
License Number d Lic.Class� ,
IL
ID
Contraor `bate / , _
rt U
❑ `7 Plan check fee D
am exempt under Sec.
BAP.C.for this reason PERMIT ISSUING FEE$ 1p Q _.I
Date: o 7..10
TOTAL FEE_ s. TTP d
Signature t!
PLAN CHECK APPLICANT .} i__! -�;fj_ ", ,i1 _;��
OWNER-BUILDER DECLARATION 01
hereby affirm that I am exempt from the Contractor's License Law NAME , :