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WORKER'S COMPENSATION DECLARATION 48DPW8/89 APPLICATION FOR PERMIT LIME GREEN,
I76A3
I hereby,atnt�fl
- at I have a certificate of consent to self Insure, 76A364C
or a csrtifloate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
pcopy fliereof(Sec.,;3800 LLabb...C. !�tl/
'empany IMMAl- ��Ir_�
❑ COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hilreby furnished.
Certified copy is filed with th?10N
bull ' Inspection FOR APPLICANT TO FILL IN BUILDING
depart nt. Y p (PRINT OR TYPE ONLY) ADDRESS
Date ApplicaUL LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMROM WORKERS' NEARESST.T ,{ p Q V gl
COMPENSATION INSURANCE CROSS OR /i „
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. Q
COMPRESSOR,BTU APPROVALS DATE INSPECTOR'S SIGNATURE
Date 116— 30 — Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAUX,GRAVITY /j �//� I ATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that 1 am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect. I
License Number Lic.Classes
Opp. 101
d 1
Contractorer/�r1 c�/�n�i�7F'l�✓� I?
C
F1Plan check fee
I am exempt under Sec. d
B.&P.C.for this reason PERMIT ISSUING FEE$ & Sv F
Date: TOTAL FEE �Q G
Signature (/
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION D ANG• _ G
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
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not Intended or offered for sale (Section 7044, "'-
Business and Professions Code). OWNER •`;2 00
❑ I, as owner of the property, am exclusively contracting . :1-
with licensed contractors to construct the project (Sec- ADDRESS XAIL2)``6 6l. IkO t7r
_.
tion 7044, Business and Professions Code). CITY T�°uydl� SIT/ TEL.NO&W'-Z"1;- -
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for CONTRACTOR �N fj� �/V _
I performance of the work for which this permit Is issued /�+ X7 »
(Sec.3097,Civ.C.). �
ADDRESS J Al, est 4 ill' T.i..
Lender's Name
CITY S '��� TEL.NO��� /J7
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. o�+�� �r 2. CLASS C
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
proper for Inspe tion purposes. / SEE REVERSE FOR EXPLANATORY LANGUAGE
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SIGNATURE OF APPLICAbPr 9A AGENT 6 DATE