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DECLARAT
N(Othat I have
a certificate
of consent to 76A346DPW9189 APPLICATION FOR PERMIT GREEN
76A364C
I 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
copy thereof(Sec.3800 Lab. C.) LJ
Policy No !fl 0 2 Company S `A1� COUNTY OF'hOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
BUILDING
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRESS
department. (PRINT OR TYPE ONLY)
Date _1 I Applicant � LOCALITY 7 �!> G -CNEARVl _
PP NO. TYPE OF APPLIANCE OR EQUIPMENT. FEE (1E�
CROS ST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
This section need not be completed if the work involved b the ASSESSOR
( P Y MAP BOOK 3 PAGE �,� PARCEL -
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU �v 0
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE .INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL -1
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU Z7VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED-UNIT-
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Number Lia ClassLA>F Tup-IJ 2 ox,
CL
Contractor ate — 0 U
❑ I am exempt under Sec. Plan Check fee O
B.&P.C.for this reason PERMIT ISSUING FEE$ 00
0
e:--�— TOTAL FEE a
Signature 4. (n
. OWNER-BUILDER DECLARATI PLAN CHECK APPLICANT
Z
I hereby affirm that I am exempt from the Co tractor'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 a _
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, n ---
Business and Professions Code). OWNER u \ f t z; ._,
❑ I, as owner of the property, am exclusively contracting MAILVVV t d ^" ;f-il
11:with licensed contractors to construct the project (Sec- ADDRESS Ems/ `-€(•sE
tion 7044, Business and Professions Code). _ f-,•): ' z' I
CITY TEL.NO. .3s ` � •I5 i
CONSTRUCTION LENDING AGENCY _ -
I•hereby affirm that there is a construction lending agency for
u
the performance of the work for which this permit Is issued CONT ACTOR
(Sec.3097,Civ. C.).
ADDRESS
Lender's Name
CITY TEL.NO.
J
%Lender's Addresss�
STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. CLASS
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
repress tatives of this County to enter upon the above-mentioned
prope for ins ction oses. d SEE REVERSE FOR EXPLANATORY LANGUAGE
L
SIG ATURE OF APPLICANT OR AGENT DTE