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WUrm th I havNSA erti DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
iifsur`e, or"a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C.) �7p6A364C
Policy No. Company t-As C YA-0046 DPW 9/88
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
,
FV Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING,/,4 st �^G
tion department. ADDRESS a
(PRINT OR TYPE ONLY) ,
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEM FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU. DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars(;100)or less.)
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM y� Q
permit is issued, I shall not employ any person in any manner BOILER, BTU !/C
so as to become subject to the Workers'Compensation Laws. APPROVALS DATE INSPECTOR'S SIGNATURE
Dat Applicant 3 COMPRESSOR, BTU O Q ROUGH
NOTICE TO APPLCA
INT: If; of eking this Certificate of VENTILATION SYSTEM FINAL —�
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth,- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be deem-
ed revoked. CE: FAU BTU VIN
FURNA
I LICENSED CONTRACTORS DECLARATION _
I hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPENDED UNIT—
(commencing with Section 7000)of Division 3 of the Business WALL.
and Professions Code,and my license is in full force and effect. �a0 0� (�o� �
License Number Lic. Class C' ZO Cec , 0
V
Contractor Date (: !9-0^a b OC
, O
❑ I am exempt under Sec.' I
Plan check fee u
B.BP.C. for this reason Z
PERMIT ISSUING FEE $
Date:
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Business and NAME ,
Professions Code):
ADDRESS
F1 '+
I, as owner of the property, or my employees with I 7_
wages as their sole compensation,will do the work and CITY TEL. NO.
the structure is not intended or offered for sale(Section ACCT rT
7044, Business and Professions Code). OWNER /� 127.00
❑ I, as owner of the property, am exclusively contracting G PYP rncO�� .6•507
with licensed contractors to construct the project (Sec- MAIL 1 ITEM
tion 7044, Business and Professions Code). ADDRESS f/� P
CONSTRUCTION LENDING AGENCY I4� TEL. NO. �U�—�3 T1:�TAL 1.27 -00
FTY;'i hereby affirm that there is a construction lending agency for
!the performance of the work for which this permit is issued CONTRACTOR ®^ ��yt CHECK`
(Sec. 3097, Civ. C.). =00
ADDRESS CHANGE
I
�-G L t�
Lender's Name
CITYC; TEL. NO.35-D —44 7,9
Lender's Address _
I certify that I have read this application and state that the STATE
LICENSE NO.3 ��5 7 CLASS G — { �''�'
above information is correct. I agree to comply with all County V:51 1 (''''
ordinances and State laws relating to building construction, I I
and hereby authorize representativesof this County to enter
upon the above- tinned propepV for inspe tionpur oses
SEE REVERSE FOR EXPLANATORY LANGUAGE
' i
i at of Applicant or Agent I Date