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WORKER I have ION
OF consent to DPW 910 APPLICATION FOR PERMIT AIME GREEN
I hereby affirm 4hat I have a certificate o€consent to self Insure 76A3840
or a certificate of Worker a Compensation Insurance or a certified HEATING VENTILATING AIR CONDITIONING
copy thereof(Sec 3800 Lab C)
Policy No 4974 Company S'�17� ��� COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
Certified copy is hereby furnished
Certified copy Is filed with the county, uilding Inspection FOR APPLICANT TO FILL IN BUUIL II G v�
department (PRINT OR TYPE ONLY) ADDRSS
Applicant �s NO TYPE OF APPLIANCE OR EQUIPMENT FEE NEARESAJe
LOCAUVT
CERTIFICATE OF EXEMPTION FROM RKERS NEAREST tT
CROSS ST
COMPENSATION INSURANCE
ABSORPTION UNIT BTU ASSESSOR
(This section need not be completed If the work Involved byhe MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less) AIR HANDLING UNIT CFM pgSpICT NO 8Y
I certify that In the performance of the work for which this permit
is Issued I shall not employ any person in any manner so as to BOILER BTU C Q�
become subject to the Workers Compensation Laws �J
COMPRESSOR BTU O �
Date Applicant APPROVALS DATE INSF3" SIGNATURE
VENTILATION SYSTEM
NOTICE TO APPLICANT If after making this Certificate of ROUGH
Exemption you should become subject to the Workers Compensation EVAPORATIVE COOLER
provisions of the Labor Code you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked FURNACE FAU RAVITY
LICENSED CONTRACTORS DECLARATION FLOOR —BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code and my license Is In full force and effect
License NumberLIc Clew LIQ
'i+ � a
Contractor Date—r–� 8
❑ I am exempt under Sac Plan check fee Q
B&P C for this reason PERMIT ISSUING FEE$ U
Date TOTAL FEE �9 �1� LU
Signature y
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT Z
I hereby affirm that I am exempt from the Contractor a License Law NAME , 1
for the following reason(Section 7031 5 Business and Professions
Code) ADDRESS ACC eY
❑ I as owner of the property or my employees with wages �n�
as their sole compensation will do the work and the CITY TEL NO J�7tJr7 1W.90
structure is not Intended or offered for sale(Section 7044
Business and Professions Code) OWNER i �'� 1 iT❑ ae�tt� o I as owner of the property am exclusively contracting MAIL TOTAL 10 • 70
with licensed contractors to construct the project (Sec ADDRESS
tion 7044 Business and Professions Code) ` OECK 109.90
CONSTRUCTION LENDING AGENCY CITY .y L TEL NO .-/ a6�
I hereby affirm that there Is a construction lending agency for CONTRACTOR , �rwa .00the performance of the work for which this permit Is Issued 7f
(Sec 3097 Civ C)
ADDRESS a �� 1 1/30/96
Lender s Name CITY � TEL NO 471-,4 4576 1 AH11:28
Lender s Address / /
I certify that I have read this application and state that the above LICAENNSE NO S.—D 6 LIC
�l� Zp
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
SIGNATOR- E�P i OR MEW ��DATE