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DECLARATION 20-00411 DPW arm APPLICATION FOR PERMITLIME' GREEN
I hereby eNlrTq tial (have a certlllcate of consent to Bell insure ]BA384C
or a,certdlcate of Worker a Compensation Insurance or a certified ^ " HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec/9'8/00 Lab C) jr [ ./, 0 -
Pplloy No �LT;r!/1_ Comp"`"f'O r✓ r•l�Y _
❑ COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
CertiRed copy is hereby furnished I I `
de copy lamed with the ca;nry building me xtwn FOR (PRINT OR TYPE ONLY) IN DDRI�
—Z _ Y n LOCALITY
DMB Ycertl NO TYPE OF APPLIANCE OR EQUIPMENT FEE
r CERTIFICATE OF EXEMPlaFROM WORD - NEAREST
CRO98 S
COMPENSATION INSURANCE ABSORPTION UNITT BTU `
(This section need not be completed B the work Involved by the permitMSM SSSOOR PAGE < PARCEL
le for one hundred dollars({70N ,
0)or u) AIR HANDLING UNITCFM
I certify that In the performance of the work for which this permit Ixem¢,ro BY
Is issued I shell not employ any person In any manner so as to BOILER,BTU
�(b�eco )act to the Workers Compenaatlon Laws + �p
V' Iia` COMPRESSOR BTU V u. SD
Date�Appknant
VENTILATION SYSTEM rsrnovlua Dore ewgaAnwe
NOTI 7y P (CANT If after me I this Csrtl to of
ROUGH _3 n• .
Exemption you ehauW become sublecl to t e Workero Com rmetwn Et,�RA�COOLER
provisions of the Labor Code you,muat forthwith comply with Such FINAL
prowstone or this permit shall be deemed revoked - FURNACE FAU_GRAVI Y
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 8 WALL SUSPENDED U ��
(commencing with Section 7000) of Division 3 of the Business and 6V HEATER
Professions Code and my license Is In full force and effect lD HES 4• ' �� '
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License Number�E k Claes r(i _ //
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Contractor De�e�?9 , �tlllU:l-f-Il'i{1 ,i_ L "Q
❑ I empt under Se Plan Check fee
B eP C for mm reason PERMIT ISSUING FEES R7
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17. "' UTOTAL FEE %
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Signature L a
uILDER DECLO66PLAN CHECK APPLICANT - �Q f^I 1 i i1 s (n
1 hereby affirm that I ern exempt from the Contractor a License Lew I1L ?
for the following reason (Section 7031 5 Business,and Professions NAME CHECK 117.715
Code)
❑ I as owner of the property or my employees with wages AGGRESS CHANGE
as, their sole compensation will do the work and the CITY TEL NO
structure is not Intended or offered for sale(Section 7044
Business end Professions Code) OWNED V.•T 4 n ff j1
1 L'i
G J
E3I as, owner of the property em exclusively contracting
with licensed contractors to construct the project (Sec MAIADDPESS —a7oo
ton 7044 Business and Profeselone Code) [� D//��� r
CONSTRUCTION LENDING AGENCY Cm a^4' TEL Np O
I hereby affirm that there Is a construction lending agency for �t / ��
the performance o1 the work for which this permit 4a Issued CONTRACTOR J19-Nb _ ff�j
(Sec 3087 Civ C)
Lander a Name �/�
CRY ' 'N TEL NO 3v—b 7w'
Lender a Address STATE LM:
I certify that I have read this application and state that the above LICENSE ND CLASS
info ma on is correct I agree to comply with all County ordlnarrcae ,,``�f� -
and State lam relating to Wilding construction and hereby authorize
representatives of this County to enter upon the above-mentioned -
property fo Inspecton gees SEE REVERSE FOR EXPLANATORY LANGUAGE