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DECLARATI
1yORKER'SCOMPENSATate of consent to 76A34SDPW9,ae APPLICATION FOR PERMIT LIME GREEN
76A964C
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
copy4hereof(Sec.3800 Lab.C.)
Policy No. 4 Company E COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnish- —/20-Z/
Certified copy Is filed with the count buildingInspection FOR APPLICANT TO FILL IN BUILDING 6 �C ��L
department. y p (PRINT OR TYPE ONLY) ADDRESS Z I
Date 2 Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. N /V
(This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL
ABSORPTION UNIT,BTU ASSESSOR
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PR ESSED er
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. ��
Z COMPRESSOR,BTU ��000J
Date Applicant VENTILATION SYSTEM APPROVALS DATE I PECTOR's SIGNATU
NOTICET APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. Z FURNACE: FAUZ2EGRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDAT ON
I hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT
:
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
110 t r5f ?,o
License Number CQ 7 13 0 Lic.Class z0
12
Contractors- Date (? k ACCT.g C
EJI am exempt under Sec. AD / Ian check fee
3303 179.90 a
BAP.C.for this reason PERMIT ISSUING FEE$ 90 1 ITEMS F
Date: 11
TOTAL FEE p TOTAL :A79 e 90 u
Signature PLAN CHECK APPLICANT CHECK
OWNER-BUILDER DECLARATION 179-94 U
G
I hereby affirm that I am exempt from the Contractor's License Law NAME , CHANGE s04
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS
I, as owner of the property, or my employees with wages 0444-0001 5/78/90
as their sole compensation, will do the work and the CITY TEL.NO. +�
structure is not intended or offered for sale (Section 7044, 6627 1 PM 4:54
Business and Professions Code). OWNER gJMAgp 1
❑ 10
I, as owner of the property, am exclusively contracting MAIL !�
with licensed contractors to construct the project (Sec- ADDRESSAVE
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITYAMARA-
TEL.NO. 5 /Z�rj
I hereby affirm that there is a construction lending agency for CONTRACTOR ,
the performance of the work for which this permit Is issued SIJ Q -
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name Q
CITYpia TEL.NO. 274
Lender's Address
I certify that I have read this application and state that the above LICENSE NO. 3 LIC.
0100
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