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WORKE SCOMPENSATjO1VDECLARATION 2U-UD46DPW 9,89 APPLICATION FOR PERMIT LIME GREEN
76A364C
1 hereby affirm thahave a eprtificate of consent to self insure,
or a certihcate of Worker's Compensation Insurance, ora certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec. 3800 Lab.C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑
Certified copy is hereby furnished.
❑ Certified co is filed with the count buildingInspection FOR APPLICANT TO FILL IN BUILDING
. y PRINT OR TYPE ONLY ADDRESS t A.
,
department. ( )
Date Applicant LOCALITY -
Pp NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE 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 D {/
become subject to'the Workers' Compensation Laws. Q
/ O J�o��
_ COMPRESSOR,BTU
Date -1. A APPROVALS DATE INSPEC OR'S SIGNATURE
.., PPlicant � VENTILATION SYSTEM.
NOTIC 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
LICENSED CONTRACTORS DECLARATION FLOOR BTU /p VALIDATION
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 NumberVia'(t�G )_T-Lic.Class Ah-, ► o
Contractor Date
❑ I am exempt under Sec. Plan Check fee
B.&P.C.for this reason PERMIT ISSUING FEE O
Date: TOTAL FEE U
W
Signature n-
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT t
hereby affirm that I am exempt from the Contractor's License Law NAME101110. A
%I/+for the following reason (Section 7031.5, Business and Professions .®r 122.50�
Code): ADDRESS `4`� , 122.5 I
❑ I, as owner of the,property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO.- 1 ITEMS
structure is not intended or offered for sale (Section 7044, TOTAL
Business and Professions Code). OWNER p, OTAL 1225
I, as owner of the property, am exclusively contracting MAIL6
3.C, CHECK 122 5
with licensed contractors to construct the project (Sec- ADDRESS h _ ,.,.e'rV
tion 7044, Business and Professions Code). / I CHANGE �'y
CONSTRUCTION LENDING AGENCY CITY TEL-NO. �! rr "t?�.
I hereby affirm that there is a construction lending agency for ;
the'performance of the work for which this permit Is issued CONTRACTOR } - ��y0y00/� ��t}0�y0 7/ 9
(Sec. 3097,Civ. C.). _ S �' !+' - .• ': 7L', S f tJt1V`tJVQ1 !!774'`
ADDRESS .1587 1 AM 7:56
.
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 %cj
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 purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT DATE -