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IWORKEFI`5 COMPENSATION
ate of consent to 7SA348DPW9i89 APPLICATION FOR PERMIT LIME GREEN
76A364C
I hereby affirm that I have a rtertiflcate 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.
B DING
F] Certified copy is filed with the county building Inspection FOR APPLICANT TO FILL IN ADDRESS G
department. (PRINT OR TYPE ONLY)
LOCALIT
Date Applicant
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS
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 �D p
become subject to the Workers'Comp! tion Laws. d
COMPRESSOR,BTU
Date �' Applicant APPROVALS DATE INSPECTOWS SIGNATURE
PP 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 GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU 9700 (DATION//�/
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.
is
License Number 3 �7 9 7- Lic.Class { -_ s
O ACCT as =
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' 'i�v' 1i_ni.5C
Contractor��j�C ���2 l9Cioate '�'� ! i (;
❑ Plan check fee
I am exempt under Sec. I LITAL 122 C
B.BP.C.for this reason PERMIT ISSUING FEE ihtrt: H1
Dy TOTAL FEE
!_i'�AN457E ,0 a
Signature GLl V,
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT (� -
I hereby affirm that I am exempt from the Contractor's License Law NAME , C4 GCI_rl-- 'F !:I i
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS 46 rte 1 iii I '+4
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
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,Business and Professions Code). Cl
CONSTRUCTION LENDING AGENCY TEL.NO.
I hereby affirm that there is a construction lending agency for t
the performance of the work for which this permit Is issued CONTRACTORCA41 AW
(Sec.3097,Civ.C.).
ADDRE 18
i
Lender's Name
CITY �r �/,� TEL.NO.�� gf f
Lender's Address p (J /�I S
I certify that I have read this application and state that the above LICENSE NO� cR 7t� LIC_
Information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
represent ' s of this County to enter upon the above-mentioned
props�fo�rnspection gurp� SEE REVERSE FOR EXPLANATORY LANGUAGE
rJj/��
SIO RE OF APPLICANT OR AGENT DATE