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DECLARATI
fWORkER'have a certificate
of consent to 76A346DPW9,69 APPLICATION FOR PERMIT LIME GREEN,
76A364C
I,hereby a'ffYtm,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 No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING0549
department. (PRINT OR TYPE ONLY) ADDRESS ! '
LOCALITY
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. G
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work involved by the ASSESSOR
MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to I BOILER,BTU �ra p
become subject to the Workers' Compensation Laws. d [ _
COMPRESSOR,BTU
APPROVALS DTE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH s'
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL 114 2,1
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 pp HEATER: S ENDEDUNT
(commencing with Section 7000) of Division 3 of the Business and ! ' WAS
Professions Code,and my license is in full force and effect.
License Number Lic.Class
IL
' }
Contractor Date O
I am exempt under Sec.
Plan check fee 0
B.&P.C.for this reason PERMIT ISSUING FEE$ 0
Date: TOTAL FEE W
Signature PLAN CHECK APPLICANT (n
OWNER-BUILDER DECLARATION 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..a'„?t •.«•:,,;_;
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, f'
Business and Professions Code). OWNER41 T7
I, as owner of the property, am exclusively contractingMAIL ' [j 3 HE
with licensed contractors to construct the project (Sec- ADDRESS L- ' Jf r r-=tM-•: r.G i l=f
tion 7044, Business and Professions Code).'`' "`�
I Q4
CONSTRUCTION LENDING AGENCY CITY, TEL.NO.
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.).
ADDRESSl^_1'R-• "t_,Iw
Lender's Name
CITY TEL.NO. 7 '; ^.»•tt
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 rela' tc building construction,and hereby authorize
Lepentativs o this unty to enter upon the above-mentioned
t fori spe ion p pose SEE REVERSE FOR EXPLANATORY LANGUAGE
RE OF APPLICANT OR AGENT DATE