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WORKERS'COMPENSATION DECLARATION I APPLICATION FIOR PERMIT
I hereby affirm that I have a certificate of consent to self I F,
OR
or p certificate of Workers'Compensation Insurance, i
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a tified`cop {tthere f(Sec. 3800, Lab. C.) y� 1 76A364c HEATING - VENTILATING -I AIR CONDITIONING
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PolicYON o ompany N y1i '
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building iinns�ec- FOR APPLICANT TO FILL IN BUILDING
do+ cc
�artment. �i ) ADDRESS .,
6 =/f_j�/f!/ (PRINT OR TYPE ONLY) /�
Date Applicant LOCALITY A &I
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
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CERTIFICATE OF EXEMPTION 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 AIR HANDLING UNIT,CFM V
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person-in any manner I
so as to become subject to the Workers'Compensation Laws. BOILER,BTU APPROVALS DATE INS ECTOR'S SIGNAT RE
COMPRESSOR,BTU d D D ROUGH
Date Applicant
NOTICE TO APPLICANT: If, after making 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 VALIDATI
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU 13 I Y b �l
LICENSED CONTRACTORS DECLARATION FLOOR BTU (/
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: 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. 1 4 1'
License Number- i-/o 373 5- Lic. Class C,3 2? I ,
Contractor CON/'"Z h/G Date �'l a o
❑ I am exempt under Sec. us
Plan check fee P_3 S 3 9 A IL
B.&P.C. for this reason' #A
PERMIT ISSUING FEE IU # a a o. o o 8
Date: Q
Signature TOTAL FEE'
,
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ••I a x3050
I hereby affirm that I am exempt from the Contractor's License Poo
o o 3 Q 5 0 v
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
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❑ I, as owner of the property, or. ADDRESS 5 8 6 my employees with �
wages as.their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY TEL.NO.
7044, Business and Professions Code).
OWNER /? S'L e G
El 1, D
I, as owner of the property,am exclusively contracting y
with licensed contractors to construct the project (Sec- ADDRESS �e ��
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY7e fy i� ��f
oN
TEL. NO. 06_,7A
I hereby affirm that there is a construction lending agency for /� ,
the performance of the work for which this permit is issued CONTRACTOR p tj [ /�� Ojr�.
41
(Sec. 3097, Civ."C.)'.
ADDRESS 7 JN Cr-�t`•/
Lender's Name n y3 .
CITY L /P C"r TEL. NO.W-5--
Lender's Address
STATE LIC. �7
I certify that I have read this application and state that the LICENSE NO. Q,3 3 CLASS O
above 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.eriter
upon the above-mentipnodproperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or.Agent Date I