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WORKER'S I have
a certificate
of consent to 7GA340DPW9/89 APPLICATION FOR PERMIT LIME GREEN
70A364C
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.) L
1
Polley No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the county building Inspection FOR APPLICANT TO FILL IN ADDRE BUILDIs f �-
department. (PRINT OR TYPE ONLY)
Date Applicant LOCALITY
Jill- If
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
CROSS
COMPENSATION INSURANCE
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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
yta�
Is issued, I shall not employ any person in any manner so as to BOILER,BTU—
become
become subject to the Workers'Compensation Laws. �"
Date ant COMPRESSOR,BTU APPROVALS DATE INSPECTOR'S SIGNATURE
"� VENTILATION SYSTEM
NOTICE'TO APPLICANT: If, making tfis Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER FINAL -
provisions of the Labor Code,you must forthwith comply with such
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVIT�C— VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Number �� 010 Lia sy—ClasZ—� f
® f
Contractor Date - I q I' iJ -C
Plan check fee ,, 9
❑ m exempt under Sec. a
BAP.C.for this reason PERMIT ISSUING FEE$ 'elf) ITEM-3
VD 7 I OT& 110 - 10 C
Date:
TOTAL FEE 1;i rLi 0
Signature Q D .� Et 1_
PLAN CHECK APPLICANT CHANGE 2
OWNER-BUILDER DECLARATION 6
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason(Section 7031.5, Business and Professions ® r,r
Code): CIlfjl�i-IjtiILIZ lls� 3
ADDRESS
❑ I, as owner Of the property, or my employees with wages 106758 1 AM 8;111-1
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). OWNS
❑ 1, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work,for which this permit Is issued
(Sec.3097,Civ.C.).
ADDRESS/ L�
Lender's Name
CITY TEL.N011411- 2
Lender's Address STATE / LIC.
I certify that I have read this application and state that the above LICENSE No d O CLASS
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
property-fot ip action purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
� ` '3
SI OF A PPyi ANT OR AGENT —� DATE