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WORKER'S COMPENSATION DECLARATION 20.0046 DPW 9/09 ,APPLICATION FOR PERMIT LIFE GREEN
I he�rrebl'afftril that IY1ave a certificate of consent to self.irtsure, 76A364C Ly e
or a certificat'e,of Worker's CoLnpensetion Insurance, or`a certified - HEATING-VENTILATING-AIR CONDITIONING
copy tt'ereof(Sec.3800 Lab.C.•))
Policy NV_�c JI;.ny3 E-�J G � '��ECOUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV..
Certified copy is hereby furnished.
❑ Certified copy is filed with the count buildingFOR APPLICANT TO FILL IN BUILDING
depart nt. y inspection (PRINT OR TYPE ONLY) ADDRESS Q 2.O 6 d�• I VE r7 T
LOCALITY
Date 2 Applicant G ' S NO. TYPE OF APPLIANCE OR EQUIPMENT FEE T M L C
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. t.( C GG M A^4
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work Involved by the ASSESSOR PARCEL
MAP BOOK PAGE
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 BOILER,BTU V
become subject to the Workers'Compensation Laws. �Q O /O Q 0
COMPRESSOR,BTU
APPROVALS DATE ECTOR'S S ONATURE
Date Applicant VENTILATION SYSTEM IN
NOTICE TO APPLICANT: If, after making this Certificate of ROUGHx
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL (C-1
provisions or this permit shall be deemed revoked. FURNACE: FAU DL Rt1V1 VALID'_I N
LICENSED CONTRACTORS DECLARATION FLOOR BTU �J
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED 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. /
7 y 6 fJ-r. Ts
License Number 3 7'o'? Lic.Class
� • a
Contractor K—<— M.6 C H A N I Dr y z— 9 6 ACCT.s C
F-1I am exempt under Sec. Plan Check fee3303 126.700
B.&P.C.for this reason PERMIT ISSUING FE (' 1 ITEMS
Date: TOTAL FEE6 D TOTAL x,.26 o 70
a
Signature CHECK 126 a 70cr
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION CHANGE .00—1 hereby affirm that I am exempt from the Contractor's License Law NAME Cl CJR( 5A/J'l I 1 M Uf`1 ► o0Q
for the following reason (Section 7031.5, Business and Professions e► �t
Code): ADDRESS r`L !C s P,�r7A G L F4 2 A 7 ( '►i ��
❑ I, as owner of the property, or my employees with wages 0000-0001 11/13/95
as their sole compensation, will do the work and the CITY G/►/� rJ� TEL.NO.R-& -4-2 C,( �'7 !f�- 3277 1AM11:22
structure is not intended'or offered for sale(Section 7044, �,.
Business and Professions Code). OWNER F4ANK
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS 112—O 5 , 5A J (fv-'A B!L IA—�,71�
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY 5/�N �jC} rL I EL TEL.NO.I hereby affirm that there is a construction lendingagency for CONTRACTOR ,the performance of the work for which this permit Is issued C M C F-[p.nr1 G -
(Sec.3097,Civ.C.). ,µ
ADDRESS IZ S f` s?+N Tp CLAR—A Sir I
Lender's Name
CITY I��C-A I A TEL.NO.yl f S7f�'77 6p..
Lender's Address STATE LIC.
I certify that I have read this application and state that the above I LICENSE NO. �p �j 7� CLASS G 2—
information
information is correct, I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representativs of this County to enter upon the above-mentioned
pro f inspectipurposes, SEE REVERSE-FOR EXPLANATORY LANGUAGE
Se
.!A�JRE OF APPLICAPT OR AGENT E